Mixed network across a chain
Generated from the Parity family benefits engine (src/tasks/benefits-engine.ts). Gold is the oracle's output over 4 claims and 2 members. Out-of-network claims are measured against a 3,000 threshold on the same single member deductible balance, and out-of-network coinsurance is double the in-network rate.
Field mean
86.9
across 28 models
Models scoring 100
22
of 28
Models scoring 0
1
of 28
What the model was given
PLAN DOCUMENT — Bluebonnet PPO 1500 (synthetic)
Plan year: 2026-01-01 through 2026-12-31. All amounts are per plan year.
Deductible
Individual (in-network) ................ 1500.00
Family (in-network) .................... 3000.00
Structure .............................. EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
Out-of-network (individual) ............ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member
deductible balance. The amount above is the threshold that balance is measured
against when the service is out-of-network.
Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the
allowed amount for covered services for the remainder of the plan year.
Member cost share
Coinsurance after deductible, in-network ......... 20% member / 80% plan
Coinsurance after deductible, out-of-network ..... 40% member / 60% plan
Primary care office visit ........................ 30.00 copay
Specialist office visit .......................... 60.00 copay
Urgent care ...................................... 75.00 copay
Emergency room ................................... 400.00 copay, WAIVED if the visit results in an inpatient admission, in which case the visit is subject to the deductible and coinsurance
Generic retail pharmacy .......................... 15.00 copay
Copays do NOT credit the deductible. Copays always credit the out-of-pocket maximum.
Preventive care
In-network preventive services required to be covered without cost share are
paid at 100% of the allowed amount and are not subject to the deductible,
coinsurance, or a copay.
Basis of payment
Member cost share is calculated from the ALLOWED amount. Amounts billed above
the allowed amount are not the member's responsibility for in-network services.FAMILY ACCUMULATORS as of the moment before Claim 1
A (subscriber) deductible 900.00 out-of-pocket 900.00
B (spouse) deductible 0.00 out-of-pocket 0.00
Family total deductible 900.00 out-of-pocket 900.00
CLAIMS (adjudicate in the order listed; each claim updates the accumulators the next is measured against)
Claim 1 — 2026-05-05 — A (subscriber)
Service ......... Out-of-network specialist procedure
Network ......... Out-of-network
Billed charge ... 4440.00
Allowed amount .. 2400.00
Claim 2 — 2026-05-21 — B (spouse)
Service ......... In-network outpatient imaging
Network ......... In-network
Billed charge ... 2405.00
Allowed amount .. 1300.00
Claim 3 — 2026-06-14 — A (subscriber)
Service ......... In-network follow-up procedure
Network ......... In-network
Billed charge ... 3330.00
Allowed amount .. 1800.00
Claim 4 — 2026-07-08 — A (subscriber)
Service ......... Out-of-network diagnostic study
Network ......... Out-of-network
Billed charge ... 2960.00
Allowed amount .. 1600.00
Report the components for Claim 4, and the ending accumulators for every member and for the family.
Required keys for this item:
member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount,
ending_deductible_a, ending_oopm_a (for A (subscriber))
ending_deductible_b, ending_oopm_b (for B (spouse))
ending_family_deductible, ending_family_oopmjson{
"kind": "fields",
"tolerance": 0.011,
"fields": {
"member_responsibility": 640,
"plan_paid": 960,
"deductible_applied": 0,
"copay_amount": 0,
"coinsurance_amount": 640,
"ending_family_deductible": 3000,
"ending_family_oopm": 4380,
"ending_deductible_a": 3000,
"ending_oopm_a": 4120,
"ending_deductible_b": 0,
"ending_oopm_b": 260
}
}Every model's answer
Sorted by score. Open a row for the response and, where the vendor exposes it, the reasoning behind it.
100Claude Fable 5.1 · Anthropic18.0s · 1,185 out | 14.5s · 1,203 out | 15.5s · 1,200 out
Reasoning · 995 tokens
[omitted]json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 1,013 tokens
[omitted]json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 1,010 tokens
[omitted]json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Gemini 3.7 Flash · Google17.0s · 2,866 out | 18.3s · 2,663 out | 19.9s · 3,169 out
Reasoning · 2,671 tokens
**Adjudicating Bluebonnet PPO**
I'm currently processing the four claims sequentially as requested for the Bluebonnet PPO 1500 plan. My focus is now on finalizing the adjudication for Claim 4 and then providing the necessary ending accumulators for members A, B, and the family.
**Clarifying Deductible Mechanics**
I'm refining my understanding of how the in-network and out-of-network deductible credits interact. Specifically, I'm analyzing the statement about a single member deductible balance and how the out-of-network threshold is applied to it, aiming for a precise interpretation.
**Calculating Deductible Applications**
I'm now calculating how the out-of-network deductible applies to Claim 1, specifically Member A's situation. My focus is on determining the remaining deductible and how it impacts the subsequent coinsurance calculation.
**Determining Deductible Application**
I've completed the initial member cost-share and accumulator updates for Claim 1, confirming the plan paid $180.00 and Member A incurred $2220.00. My current focus is on understanding how the satisfied family deductible impacts Member B's deductible requirement for Claim 2, given their current $0 balance.
**Applying Embedded Deductible**
I've now calculated Member B's portion of Claim 2, including their zero deductible application due to the family deductible being met. I've also completed the accumulator updates and have moved on to processing Claim 3 for Member A, focusing on applying the in-network coinsurance.
**Finalizing Claim 4 Adjudication**
I've completed the adjudication for Claim 4, applying out-of-network coinsurance to Member A. My focus is now on determining the final accumulator balances for Member A, Member B, and the family, ensuring all calculations are precise.
json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 2,468 tokens
**Analyzing Deductible Scenarios**
I'm currently dissecting the deductible calculations, specifically examining how individual and family deductibles for both in-network (INN) and out-of-network (OON) benefits play out. My focus is on the single member OON deductible threshold.
**Calculating Deductible Reductions**
I'm now calculating the remaining deductible for A on this OON claim, considering their current accumulator of 900 against the 3000 OON individual deductible threshold. This step is crucial for accurately determining how much of the allowed amount will apply towards their deductible.
**Applying Deductible Calculations**
I've completed the deductible application for the initial out-of-network claim, successfully calculating the member's responsibility and updating all relevant accumulators. I've noted that the family deductible is now fully met following this first claim.
**Finalizing Deductible and OOPM**
I've now calculated the impact of Claim 2 on member B and the family OOPM, confirming the family deductible is met. For Claim 3, I've determined A's deductible is satisfied and computed the member's coinsurance responsibility.
**Confirming Deductible Application**
I've successfully calculated the coinsurance for Claim 4, applying the 40% member responsibility against the allowed amount after determining A's out-of-network deductible is fully met. I'm now verifying the remaining out-of-pocket maximum impacts.
json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 2,974 tokens
**Tracking Adjudication Progress**
I'm meticulously logging each claim's adjudication, paying close attention to how it impacts individual and family deductibles and out-of-pocket maximums, ensuring precise tracking against plan rules.
**Calculating Deductible Accrual**
I'm now focusing on how deductibles are applied, particularly the interplay between in-network and out-of-network spending. The current calculation is for an out-of-network claim, and I need to determine if the individual's OON deductible threshold of $3000 is the correct one to use or if the family OON deductible comes into play.
**Applying Deductible Rules**
I've refined my understanding of how out-of-network expenses apply to individual versus family deductibles. My calculations now reflect that out-of-network deductible credits accumulate to a single member's balance first. The allowed amount is then reduced by this remaining balance, with coinsurance applied to the remainder.
**Finalizing Deductible Logic**
I've confirmed that the family deductible is met once total credits reach the family amount, regardless of individual contribution. This resolved the calculation for Claim 2, and I've successfully processed Claim 3, applying coinsurance to the allowed amount as the deductible was already satisfied.
**Processing Next Claim**
I have successfully adjudicated Claim 4. My calculations confirm the out-of-network deductible is satisfied, and I've applied the coinsurance to the allowed amount. The accumulators have been updated accordingly.
**Calculating Remaining Balances**
I'm now reviewing the remaining balances after processing Claim 4. For A, the OOPM is $3120, and the deductible is met. For B, the OOPM is $260. The family OOPM stands at $3740.
**Updating Accumulators**
I have finalized the calculations for the latest claim, ensuring all dollar amounts are formatted correctly. My process now meticulously updates individual and family accumulators for deductibles and out-of-pocket maximums based on the adjudicated amount.
json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100GPT-5.5 · OpenAI10.7s · 1,062 out | 11.8s · 971 out | 6.7s · 667 out
Reasoning · 911 tokens
**Evaluating deductible and coinsurance**
I'm trying to understand the out-of-network (OON) deductible situation better. It appears that I've already met the deductible threshold of $3,000. Now, I'm considering the coinsurance, which is set at 40%. So, that would mean I might owe $640 unless the out-of-pocket maximum comes into play. I need to double-check the specifics of how this all interacts, especially regarding the out-of-pocket maximum and any further implications for my family.
**Calculating out-of-network costs**
I’m considering whether overbilling might have occurred for out-of-network (OON) services. The task specifies that costs should be part of the allowed amount. I need to calculate the family out-of-pocket (OOP) by adding up several claims, which total 4380.
I’m also looking at the nuances regarding individual versus family deductibles, particularly if reaching the family deductible means no further OON deductible applies. If the family isn't OON, I need to factor that in too. Now, it’s time to finalize my thoughts.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 820 tokens
**Considering JSON formatting**
I’m noticing a conflict here: reporting every dollar amount as a plain number with two decimal places doesn’t quite mesh with JSON numeric representation. It seems 640.00 is a valid JSON number because it shows decimals. The key is to use numeric literals with .00, which is treated the same by the JSON parser. I think I don’t need any extra formatting, so I’ll keep it straightforward!json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "4120.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3000.00",
"ending_family_oopm": "4380.00"
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": "960.00",
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4380.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100GPT-5.6 Sol · OpenAI8.9s · 507 out | 6.1s · 498 out | 6.9s · 503 out
Reasoning · 356 tokens
**Calculating deductible thresholds**
I need to calculate the deductible balance thresholds carefully. For a member embedded in a family plan, the initial individual deductible is $900, with an out-of-pocket maximum of $900; the family deductible is also $900. The out-of-network (OON) allowed amount is $2,400, with an OON threshold of $3,000.
I realize the calculations for individual and family deductibles are a bit complex, especially with the different plans involved. I'm focusing on precise numbers to ensure accuracy.
**Considering formatting for values**
I need to note that for out-of-network out-of-pocket (OOP) individual costs, it's $12,000. I’m considering how to present values, especially with decimals, likely needing to use JSON strings. The contract specifies numbers should have two decimal places. JSON doesn’t always preserve the text formatting, so I might need to stick to plain numbers like 640.00.
Given the guidelines, it's clear I should use numbers with decimals to ensure accuracy in reporting.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 347 tokens
**Clarifying deductible details**
I need to understand if the deductible accumulation can be capped differently for different plans, like Claim1 having an individual embedded threshold of 3000 while the family is also at 3000. Should dollar amounts be shown as strings or numbers? I see there's a need for "plain two decimal places," but JSON numeric formats can't retain that semantically. I’ll need to ensure I'm working with exact values that are fenced correctly.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 352 tokens
**Considering output format**
I’m thinking that for money, it's often represented with two decimal places. JSON typically treats numbers differently, which could lead to losing that appearance, especially if I just use numbers. Contracts specify amounts should display as plain two decimal without any symbol, so strings seem like the best choice here. It’s important that I return values exactly as the user expects, especially with existing tasks looking for string formats.json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "4120.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3000.00",
"ending_family_oopm": "4380.00"
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": "960.00",
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4380.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Grok 4.6 · xAI75.2s · 4,048 out | 67.6s · 4,073 out | 58.6s · 3,756 out
Reasoning · 3,892 tokens
The user wants me to adjudicate claims in order and report Claim 4 components plus ending accumulators.
Claim 4 components:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
Ending accumulators:
- ending_deductible A: 900.00
- ending_oopm A: 1,540.00
- ending_deductible B: 0.00
- ending_oopm B: 0.00
- ending_family_deductible: 900.00
- ending_family_o opm: 1,540.00 (wait, 900 + 640 = 1,540) 1,540.00 1,540.00 900.00 1,540.00
Wait, I think I made a mistake in the ending OOPM for A.
Let me recalculate the OOPM step by step.
Starting:
A: ded 900, oopm 900
B: ded 0, oopm 0
Family 900, 900
Claim 1 (A OON):
Ded applied: 2100
Coinsurance: 40% of 300 = 120
Member resp: 2220
Plan: 180
A oopm: 900 + 2220 = 3120
Family oop 900 + 2220 = 3120
Claim 2 (B IN):
Ded applied: 0
Coinsurance: 20% of 1300 = 260
Member resp: 260
Plan: 1040
B oopm: 0 + 260 = 260
Family 3120 + 260 = 3380
Claim 3 (A IN):
Ded applied: 0
Coinsurance: 20% of 1800 = 360
Member resp: 360
Plan: 1440
A oopm: 3120 + 360 = 3480 (wait, earlier I said 3480)
Family 3380 + 360 = 3740
Claim 4 (A OON):
Ded applied: 0
Coinsurance: 40% of 1600 = 640
Member resp: 640
Plan: 960
A oop 3480 + 640 = 4120
Family 3740 + 640 = 4380
Yes, ending:
ending_deductible_a: 3000.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 3,917 tokens
The user wants me to adjudicate claims in order and report for Claim 4 plus ending accumulators.
I need to clarify a few things about the plan rules before I can accurately adjudicate the claims.
First, the family deductible is listed as 3000.00, but the starting accumulators show family deductible at 900.00. That suggests the family deductible is already partially met at 900.00, so 2100.00 remains.
For out-of-network services, the individual deductible threshold is 3000.00, and the family deductible threshold is also 3000.00. Since the family deductible is already at 900.00, the remaining family deductible is 2100.00.
For Claim 1, 2100.00 of the allowed amount (2400.00) would be applied to the deductible, leaving 300.00. Then 40% coinsurance (120.00) would be the member's responsibility for the remaining amount.
After Claim 1:
- A's deductible balance: 900 + 2100 = 3000.00
- A's OOPM: 900 + 2220 = 3120.00
- Family deductible: 900 + 2100 = 3000.00
- Family OOPM: 900 + 2220 = 3120.00
For Claim 2 (B, in-network):
- Family deductible is already met (3000.00), so no deductible applied.
- 20% coinsurance on 1300.00 = 260.00
- B's OOPM: 260.00
- Family OOPM: 3120 + 260 = 3380.00
For Claim 3 (A, in-network):
- Individual deductible already met (3000.00 > 1500.00)
- Family deductible met
- 20% coinsurance on 1800.00 = 360.00
- A's OOPM: 3120 + 360 = 3480.00
- Family OOPM: 3380 + 360 = 3740.00
For Claim 4 (A, out-of-network):
- Individual deductible already met (3000.00)
- Family deductible met
- 40% coinsurance on 1600. 00 = 640.00
- Member responsibility: 640.00
- Plan paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
- A's OOPM: 3480 + 640 = 4120.00
- Family OOPM: 3740 + 640 = 4380.00
So for Claim 4:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- cop ay_amount: 0.00
- coinsurance_amount: 640.00
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
I think this is the correct adjudication based on the rules provided.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 3,600 tokens
The problem is a contested adjudication task. I need to adjudicate claims in order and report for Claim 4, plus ending accumulators.
For Claim 4, the components are:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
Ending accumulators:
- A (subscriber): ending_deductible_a 3000.00, ending_oopm_a 4320.00
- B (spouse): ending_deductible_b 0.00, ending_oopm_b 0.00
- Family: ending_family_deductible 300 0.00, ending_family_oopm 4320.00 After Claim 1 (OON), the single member deductible balance reached 3000 (900 + 2100), so the family deductible is also satisfied at 3000. Claim 2 (IN) therefore applied 0 deductible, and B’s personal deductible stayed at 0. Claim 3 (IN 1800) applied 0 deductible and 360 coinsurance, bringing A’s OOPM to 3480. Claim 4 (OON 1600) applied 0 deductible and 640 coinsurance, bringing A’s OOPM to 4120 and family OOPM to 4380. B’s OOP 260 remained unchanged. All values are rounded to two decimals.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Grok 4.5 · xAI35.1s · 2,271 out | 37.5s · 2,322 out | 28.3s · 1,908 out
Reasoning · 2,128 tokens
The problem is about adjudicating claims for a health plan. I need to process claims in order and report for Claim 4 and ending accumulators.
Claim 4 components:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
Ending accumulators:
- ending_deductible A: 3000.00
- ending_oopm A: 3760.00
- ending_deductible B: 0.00
- ending_oopm B: 260.00
- ending_family_deductible: 3000.00
- ending_family oopm: 4040.00 (wait, let me recalculate)
Wait, I think I made a mistake in the last step.
After Claim 3:
A oop: 3480
Family oop: 3740
Claim 4:
Member pays 640 (coinsurance)
So A oop: 3480 + 640 = 4120
Family oop: 3740 + 640 = 4380
Yes, earlier I said 3760 by mistake.
Correct ending:
ending_deductible_a: 3000.00
ending_oopm_a: 4120.00
ending_deductible b: 0.json{"member_responsibility": 640.00, "plan_paid": 960.00, "deductible_applied": 0.00, "copay_amount": 0.00, "coinsurance_amount": 640.00, "ending_deductible_a": 3000.00, "ending_oopm_a": 4120.00, "ending_deductible_b": 0.00, "ending_oopm_b": 260.00, "ending_family_deductible": 3000.00, "ending_family_oopm": 4380.00}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 2,179 tokens
The problem is about adjudicating claims for a health plan. I need to process claims in order and report for Claim 4 specifically, plus ending accumulators.
For Claim 4, the components are:
- member_responsibility: 1600.00
- plan_paid: 0.00
- deductible_applied: 1600.00
- copay_amount: 0.00
- coinsurance_amount: 0.00
Ending accumulators 2026-07-08:
A (subscriber):
ending_deductible_a: 3000.00
ending_oopm_a: 4720.00
B (spouse):
ending_deductible_b: 3000.00
ending_oopm_b: 3120. 00
Family:
ending_family_deductible: 3000.00
ending_family_oopm: 4720.00 The plan paid nothing because the full 1600 was applied to the deductible. The deductible balance for A reached exactly 3000 after Claim 1, so Claim 4 applied the entire allowed amount to the deductible (no coinsurance or copay).json{"member_responsibility": 640.00, "plan_paid": 960.00, "deductible_applied": 0.00, "copay_amount": 0.00, "coinsurance_amount": 640.00, "ending_deductible_a": 3000.00, "ending_oopm_a": 4120.00, "ending_deductible_b": 0.00, "ending_oopm_b": 260.00, "ending_family_deductible": 3000.00, "ending_family_oopm": 4380.00}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 1,765 tokens
The problem is about adjudicating claims for a health plan. I need to process claims in order and update accumulators.
Claim 1 adjudication:
- deductible_applied: 2100.00
- coinsurance_amount: 120.00
- copay_amount: 0.00
- plan_paid: 180.00
- member_responsibility: 2220.00
A’s ending_deductible_a 3000.00
A’s ending_oopm_a 3120.00
B unchanged
Family ending_deductible 3000.00
Family ending_oopm 3120.00
Claim 2 adjudication:
- deductible_applied: 0.00
- coinsurance_amount: 260.00
- copay_amount: 0.00
- plan_paid: 1040.00
- member_responsibility: 260.00
B’s ending_deductible_b 0.00
B’s ending_oopm_b 260.00
A unchanged
Family 3000.00 / 3380.00
Claim 3 adjudication:
- deductible_applied: 0.00
- coinsurance_amount: 360.00
- copay_amount: 0.00
- plan_paid: 1440.json{"member_responsibility": 640.00, "plan_paid": 960.00, "deductible_applied": 0.00, "copay_amount": 0.00, "coinsurance_amount": 640.00, "ending_deductible_a": 3000.00, "ending_oopm_a": 4120.00, "ending_deductible_b": 0.00, "ending_oopm_b": 260.00, "ending_family_deductible": 3000.00, "ending_family_oopm": 4380.00}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Gemini 3.1 Pro · Google36.6s · 4,560 out | 47.9s · 6,270 out | 68.2s · 9,549 out
Reasoning · 4,365 tokens
**Adjudicating Claims for the Bluebonnet PPO 1500 Plan**
My task is to adjudicate four claims for a family under the "Bluebonnet PPO 1500" plan for the 2026 plan year. I need to track how these claims affect the family's accumulators, specifically the deductibles and out-of-pocket maximums, and then provide the final accumulator values. I also need to detail the components of the fourth claim.
First, I've reviewed the plan's structure and thresholds:
* **Deductible:** Individual INN is $1500, Family INN is $3000. Individual OON is $3000. Critically, the plan states that INN and OON deductible credits accumulate to a SINGLE member deductible balance, and this single balance is measured against the respective OON threshold when the service is out-of-network. The family deductible is met when the sum of member credits reaches the family threshold.
* **Out-of-Pocket Maximum (OOPM):** Individual INN is $6000, Family INN is $12000. Individual OON is $12000. The prompt implies a single, unified OOPM accumulator for both INN and OON, as no separate balances are tracked initially, and the plan language refers to "the out-of-pocket maximum" generally.
* **Coinsurance:** INN is 20% member / 80% plan. OON is 40% member / 60% plan.
* **Family Structure:** Embedded.
I'm starting with the following accumulator balances:
* Member A: Deductible $900.00, OOP $900.00
* Member B: Deductible $0.00, OOP $0.00
* Family: Deductible $900.00, OOP $900.00
Now, I'll process each claim chronologically:
**Claim 1 - 2026-05-05 - Member A (Out-of-network specialist procedure)**
* Allowed amount: $2400.00
* Member A's current OON deductible balance is $900.00. The OON individual deductible threshold is $3000.00, meaning $2100.00 more is needed to meet A's individual OON deductible.
* The amount applied to A's deductible is the minimum of the allowed amount ($2400.00) and the remaining deductible ($2100.00), which is $2100.00.
* This $2100.00 is applied to A's deductible balance, bringing it to $3000.00.
* The remaining allowed amount is $2400.00 - $2100.00 = $300.00.
* OON coinsurance is 40% of the remaining allowed amount: 0.40 * $300.00 = $120.00.
* Member A's total cost share for this claim is $2100.00 (deductible) + $120.00 (coinsurance) = $2220.00.
* Member A's OOP accumulator increases by $2220.00, from $900.00 to $3120.00.
* The family deductible balance is now Member A's $3000.00 + Member B's $0.00 = $3000.00. This meets the Family INN Deductible threshold of $3000.00, which is important for subsequent claims.
* **Accumulators after Claim 1:**
* A: Deductible $3000.00, OOP $3120.00
* B: Deductible $0.00, OOP $0.00
* Family: Deductible $3000.00, OOP $3120.00
**Claim 2 - 2026-05-21 - Member B (In-network outpatient imaging)**
* Allowed amount: $1300.00
* This is an in-network service. The INN individual deductible is $1500.00, and the INN family deductible is $3000.00.
* Since the family deductible balance is already $3000.00 (met by Claim 1's credits), the family INN deductible is satisfied. Because the family deductible is met, Member B does not need to meet their individual deductible.
* Deductible applied to B: $0.00.
* INN coinsurance is 20% of the allowed amount: 0.20 * $1300.00 = $260.00.
* Member B's cost share is $260.00.
* Member B's OOP accumulator increases by $260.00, from $0.00 to $260.00.
* The family OOP accumulator increases by $260.00, from $3120.00 to $3380.00.
* **Accumulators after Claim 2:**
* A: Deductible $3000.00, OOP $3120.00
* B: Deductible $0.00, OOP $260.00
* Family: Deductible $3000.00, OOP $3380.00
**Claim 3 - 2026-06-14 - Member A (In-network follow-up procedure)**
* Allowed amount: $1800.00
* This is an in-network service. Member A's deductible balance is $3000.00, which exceeds their individual INN deductible of $1500.00. Furthermore, the family INN deductible is already satisfied.
* Deductible applied to A: $0.00.
* INN coinsurance is 20% of the allowed amount: 0.20 * $1800.00 = $360.00.
* Member A's cost share is $360.00.
* Member A's OOP accumulator increases by $360.00, from $3120.00 to $3480.00.
* The family OOP accumulator increases by $360.00, from $3380.00 to $3740.00.
* **Accumulators after Claim 3:**
* A: Deductible $3000.00, OOP $3480.00
* B: Deductible $0.00, OOP $260.00
* Family: Deductible $3000.00, OOP $3740.00
**Claim 4 - 2026-07-08 - Member A (Out-of-network diagnostic study)**
* Allowed amount: $1600.00
* This is an out-of-network service. Member A's deductible balance is $3000.00, and the OON individual deductible threshold is also $3000.00. Therefore, A's OON deductible is already met.
* Deductible applied to A: $0.00.
* OON coinsurance is 40% of the allowed amount: 0.40 * $1600.00 = $640.00.
* Member A's cost share is $640.00.
* Member A's OOP accumulator increases by $640.00, from $3480.00 to $4120.00.
* The family OOP accumulator increases by $640.00, from $3740.00 to $4380.00.
* Neither Member A's nor the Family's OOPM ($6000/$12000 and $12000 respectively) has been reached by these costs.
**Final Accumulators:**
Based on the adjudication of these four claims, the final accumulator balances for the plan year 2026 are:
* **Member A:**
* Ending Deductible: $3000.00
* Ending Out-of-Pocket: $4120.00
* **Member B:**
* Ending Deductible: $0.00
* Ending Out-of-Pocket: $260.00
* **Family:**
* Ending Deductible: $3000.00
* Ending Out-of-Pocket: $4380.00
**Claim 4 Components:**
For Claim 4 (Out-of-network diagnostic study for Member A, Allowed amount $1600.00), the breakdown of costs is:
* **Member Responsibility:** $640.00
* **Plan Paid:** $960.00 (which is $1600.00 allowed - $640.00 member responsibility)
* **Deductible Applied:** $0.00
* **Copay Amount:** $0.00
* **Coinsurance Amount:** $640.00
json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 6,075 tokens
**Plan Analysis and Claims Processing**
Okay, let's break down what's happening here with the Bluebonnet PPO 1500 plan for the 2026 plan year. I need to track the deductibles and out-of-pocket maximums as claims come in, ensuring accuracy for both individual members and the family as a whole.
The core details are:
* **Plan:** Bluebonnet PPO 1500 (synthetic)
* **Plan Year:** January 1, 2026, to December 31, 2026
* **Deductibles:**
* In-Network (INN) Individual: $1,500
* In-Network (INN) Family: $3,000
* Out-of-Network (OON) Individual: $3,000
* *Crucially, INN and OON deductible credits accumulate to a single member deductible balance. This means if I satisfy the $3,000 OON deductible for an individual, it also counts towards their $1,500 INN deductible and contributes to the $3,000 family deductible.*
* **Out-of-Pocket Maximums (OOPM):**
* INN Individual: $6,000
* INN Family: $12,000
* OON Individual: $12,000
* *It appears that all OOPM counts (INN and OON, individual and family) accumulate into a single, overall family OOPM balance.*
Now, let's look at the initial state of our accumulators:
* **Subscriber (A):**
* Deductible: $900.00
* OOPM: $900.00
* **Spouse (B):**
* Deductible: $0.00
* OOPM: $0.00
* **Family Total:**
* Deductible: $900.00
* OOPM: $900.00
Now, I'll process each claim sequentially, updating the accumulators as I go.
***
**Claim 1 - May 5, 2026 - Subscriber (A)**
* **Service:** OON Specialist Procedure
* **Network:** Out-of-Network (OON)
* **Billed:** $4,440.00
* **Allowed:** $2,400.00
This is an OON service for Subscriber A. A's OON individual deductible is $3,000. They've already met $900 of it. So, A needs to meet another $2,100 ($3,000 - $900) to satisfy their OON deductible.
Since INN and OON deductibles contribute to a single member balance, this $2,100 also counts towards the family deductible. The family deductible is $3,000, and they've already met $900, leaving $2,100 to meet. So, this claim will satisfy the remaining deductible for both A's OON individual deductible and the family deductible.
* **Deductible Applied:** $2,100.00 (This satisfies A's OON deductible, and the family deductible).
* **Remaining Allowed Amount (after deductible):** $2,400.00 - $2,100.00 = $300.00
* **OON Coinsurance:** 40%. So, the member's share is 40% of $300.00 = $120.00.
* **Plan Paid:** $300.00 - $120.00 = $180.00
* **Total Member Responsibility for this claim:** $2,100.00 (deductible) + $120.00 (coinsurance) = $2,220.00
**Accumulators After Claim 1:**
* **Subscriber (A) Deductible:** $900.00 + $2,100.00 = $3,000.00 (Satisfied)
* **Subscriber (A) OOPM:** $900.00 + $2,220.00 = $3,120.00
* **Spouse (B) Deductible:** $0.00
* **Spouse (B) OOPM:** $0.00
* **Family Total Deductible:** $900.00 + $2,100.00 = $3,000.00 (Satisfied)
* **Family Total OOPM:** $900.00 + $2,220.00 = $3,120.00
***
**Claim 2 - May 21, 2026 - Spouse (B)**
* **Service:** INN Outpatient Imaging
* **Network:** In-Network (INN)
* **Billed:** $2,405.00
* **Allowed:** $1,300.00
This is an INN service for Spouse B. The family deductible is $3,000. As we saw from Claim 1, the family deductible has already been fully met ($3,000). Therefore, there is no deductible to apply for this claim.
* **Deductible Applied:** $0.00
* **Remaining Allowed Amount (after deductible):** $1,300.00
* **INN Coinsurance:** 20%. So, the member's share is 20% of $1,300.00 = $260.00.
* **Plan Paid:** $1,300.00 - $260.00 = $1,040.00
* **Total Member Responsibility for this claim:** $260.00 (coinsurance)
**Accumulators After Claim 2:**
* **Subscriber (A) Deductible:** $3,000.00
* **Subscriber (A) OOPM:** $3,120.00
* **Spouse (B) Deductible:** $0.00
* **Spouse (B) OOPM:** $0.00 + $260.00 = $260.00
* **Family Total Deductible:** $3,000.00
* **Family Total OOPM:** $3,120.00 + $260.00 = $3,380.00
***
**Claim 3 - June 14, 2026 - Subscriber (A)**
* **Service:** INN Follow-up Procedure
* **Network:** In-Network (INN)
* **Billed:** $3,330.00
* **Allowed:** $1,800.00
This is an INN service for Subscriber A. A's INN individual deductible is $1,500, but their overall member deductible balance is already $3,000 (from Claim 1). Since the deductible is fully met, no deductible applies to this claim.
* **Deductible Applied:** $0.00
* **Remaining Allowed Amount (after deductible):** $1,800.00
* **INN Coinsurance:** 20%. So, the member's share is 20% of $1,800.00 = $360.00.
* **Plan Paid:** $1,800.00 - $360.00 = $1,440.00
* **Total Member Responsibility for this claim:** $360.00 (coinsurance)
**Accumulators After Claim 3:**
* **Subscriber (A) Deductible:** $3,000.00
* **Subscriber (A) OOPM:** $3,120.00 + $360.00 = $3,480.00
* **Spouse (B) Deductible:** $0.00
* **Spouse (B) OOPM:** $260.00
* **Family Total Deductible:** $3,000.00
* **Family Total OOPM:** $3,380.00 + $360.00 = $3,740.00
***
**Claim 4 - July 8, 2026 - Subscriber (A)**
* **Service:** OON Diagnostic Study
* **Network:** Out-of-Network (OON)
* **Billed:** $2,960.00
* **Allowed:** $1,600.00
This is an OON service for Subscriber A. A's OON individual deductible is $3,000, and their member deductible balance is already $3,000 from Claim 1. Therefore, no deductible applies to this claim.
* **Deductible Applied:** $0.00
* **Remaining Allowed Amount (after deductible):** $1,600.00
* **OON Coinsurance:** 40%. So, the member's share is 40% of $1,600.00 = $640.00.
* **Plan Paid:** $1,600.00 - $640.00 = $960.00
* **Total Member Responsibility for this claim:** $640.00 (coinsurance)
**Accumulators After Claim 4:**
* **Subscriber (A) Deductible:** $3,000.00
* **Subscriber (A) OOPM:** $3,480.00 + $640.00 = $4,120.00
* **Spouse (B) Deductible:** $0.00
* **Spouse (B) OOPM:** $260.00
* **Family Total Deductible:** $3,000.00
* **Family Total OOPM:** $3,740.00 + $640.00 = $4,380.00
***
**Final Values:**
* **Member Responsibility (Claim 4):** $640.00
* **Plan Paid (Claim 4):** $960.00
* **Deductible Applied (Claim 4):** $0.00
* **Copay Amount (Claim 4):** $0.00 (No copay was applicable for this service.)
* **Coinsurance Amount (Claim 4):** $640.00
* **Subscriber (A) Ending Deductible:** $3,000.00
* **Subscriber (A) Ending OOPM:** $4,120.00
* **Spouse (B) Ending Deductible:** $0.00
* **Spouse (B) Ending OOPM:** $260.00
* **Family Total Ending Deductible:** $3,000.00
* **Family Total Ending OOPM:** $4,380.00
json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 9,354 tokens
**Plan Year 2026 Claims Adjudication Walkthrough**
Alright, let's break down these claims based on the Bluebonnet PPO 1500 plan for the 2026 plan year. This is a synthetic plan, meaning the details are defined for the purpose of this exercise.
First, I've noted the core benefit structure:
* **Plan Year:** January 1, 2026, to December 31, 2026.
* **Deductibles:**
* Individual (In-Network): $1,500
* Family (In-Network): $3,000
* Individual (Out-of-Network): $3,000
* Crucially, the document states that "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." This is a key detail—all deductible expenses, regardless of network, pool into one balance per member, and these member balances then contribute to the family deductible.
* **Out-of-Pocket Maximums (OOPM):**
* Individual (In-Network): $6,000
* Family (In-Network): $12,000
* Individual (Out-of-Network): $12,000
* The document doesn't explicitly state that OOPM credits accumulate to a *single* balance like deductibles do. However, based on how the initial accumulator values are presented (a single "out-of-pocket" amount per member), I'm proceeding under the assumption that OOPM also accumulates in a single pool per member, with network status influencing which maximum applies.
Now, let's track the accumulators and claims:
**Initial State (Before Claim 1):**
I see that A (the subscriber) has already met some deductible and OOPM costs.
* A's Deductible: $900.00
* A's OOPM: $900.00
* Family Total Deductible: $900.00
* Family Total OOPM: $900.00
* B (spouse) has $0.00 applied to their deductible or OOPM.
---
**Claim 1 (May 5, 2026): A (Subscriber) - Out-of-Network Specialist Procedure**
* **Service:** Out-of-Network Specialist Procedure
* **Network:** OON
* **Billed:** $4,440.00
* **Allowed:** $2,400.00
Here's how I'd process this:
* A's current deductible balance is $900.00.
* The individual Out-of-Network deductible threshold is $3,000.00.
* To meet A's individual OON deductible, we need $3,000.00 - $900.00 = $2,100.00.
* The allowed amount for this claim is $2,400.00. So, the first $2,100.00 of the allowed amount will go towards A's deductible.
* This leaves $2,400.00 - $2,100.00 = $300.00 of the allowed amount remaining for coinsurance.
* The OON coinsurance is 40% for the member. So, the coinsurance is $300.00 \* 0.40 = $120.00.
* A's total responsibility for this claim is the deductible applied ($2,100.00) plus the coinsurance ($120.00), totaling $2,220.00.
* The plan pays the remaining allowed amount: $2,400.00 - $2,220.00 = $180.00.
Now, updating the accumulators:
* **A's Deductible:** $900.00 (initial) + $2,100.00 (applied) = $3,000.00.
* **A's OOPM:** $900.00 (initial) + $2,220.00 (member responsibility) = $3,120.00.
* **Family Deductible:** $900.00 (initial) + $2,100.00 (applied to A's balance, which contributes to family total) = $3,000.00. This meets the Family (In-Network) deductible threshold of $3,000.00.
* **Family OOPM:** $900.00 (initial) + $2,220.00 (A's responsibility) = $3,120.00.
---
**Claim 2 (May 21, 2026): B (Spouse) - In-Network Outpatient Imaging**
* **Service:** In-Network Outpatient Imaging
* **Network:** INN
* **Billed:** $2,405.00
* **Allowed:** $1,300.00
Processing this claim:
* B's current deductible is $0.00.
* The Family (In-Network) deductible is $3,000.00. As we saw from Claim 1, the family deductible balance has already reached $3,000.00.
* The plan's structure states: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Since the family deductible has been met ($3,000.00), B's individual deductible is considered satisfied, even though B hasn't personally incurred $3,000.00 in deductible expenses.
* Therefore, B pays no deductible on this claim.
* The In-Network coinsurance is 20% for the member. So, the coinsurance is $1,300.00 \* 0.20 = $260.00.
* B's total responsibility for this claim is $260.00.
* The plan pays $1,300.00 - $260.00 = $1,040.00.
Updating the accumulators:
* **B's Deductible:** $0.00 (no change).
* **B's OOPM:** $0.00 (initial) + $260.00 (member responsibility) = $260.00.
* **Family Deductible:** $3,000.00 (no change, as B incurred no deductible).
* **Family OOPM:** $3,120.00 (initial) + $260.00 (B's responsibility) = $3,380.00.
---
**Claim 3 (June 14, 2026): A (Subscriber) - In-Network Follow-up Procedure**
* **Service:** In-Network Follow-up Procedure
* **Network:** INN
* **Billed:** $3,330.00
* **Allowed:** $1,800.00
My calculation:
* A's current deductible balance is $3,000.00.
* The Individual (In-Network) deductible is $1,500.00. Since A's deductible balance ($3,000.00) exceeds this, A has met their individual INN deductible.
* Therefore, A pays no deductible on this claim.
* The In-Network coinsurance is 20% for the member. So, the coinsurance is $1,800.00 \* 0.20 = $360.00.
* A's total responsibility for this claim is $360.00.
* The plan pays $1,800.00 - $360.00 = $1,440.00.
Updating the accumulators:
* **A's Deductible:** $3,000.00 (no change).
* **A's OOPM:** $3,120.00 (initial) + $360.00 (member responsibility) = $3,480.00.
* **Family Deductible:** $3,000.00 (no change).
* **Family OOPM:** $3,380.00 (initial) + $360.00 (A's responsibility) = $3,740.00.
---
**Claim 4 (July 8, 2026): A (Subscriber) - Out-of-Network Diagnostic Study**
* **Service:** Out-of-Network Diagnostic Study
* **Network:** OON
* **Billed:** $2,960.00
* **Allowed:** $1,600.00
My adjudication steps:
* A's current deductible balance is $3,000.00.
* The Individual (Out-of-Network) deductible threshold is $3,000.00. A has already met this threshold.
* Therefore, A pays no deductible on this claim.
* The Out-of-Network coinsurance is 40% for the member. So, the coinsurance is $1,600.00 \* 0.40 = $640.00.
* A's total responsibility for this claim is $640.00.
* The plan pays $1,600.00 - $640.00 = $960.00.
Final accumulator updates after this claim:
* **A's Deductible:** $3,000.00 (no change).
* **A's OOPM:** $3,480.00 (initial) + $640.00 (member responsibility) = $4,120.00.
* **Family Deductible:** $3,000.00 (no change).
* **Family OOPM:** $3,740.00 (initial) + $640.00 (A's responsibility) = $4,380.00.
---
**Summary of Claim 4 Results:**
* **member_responsibility:** 640.00
* **plan_paid:** 960.00
* **deductible_applied:** 0.00
* **copay_amount:** 0.00 (No copays apply to this type of service, especially OON).
* **coinsurance_amount:** 640.00
* **ending_deductible_a:** 3000.00
* **ending_oopm_a:** 4120.00
* **ending_deductible_b:** 0.00
* **ending_oopm_b:** 260.00
* **ending_family_deductible:** 3000.00
* **ending_family_oopm:** 4380.00
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Grader detail
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}100Claude Opus 5 · Anthropic12.1s · 1,097 out | 10.8s · 886 out | 10.9s · 950 out
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Grader detail
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Grader detail
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Grader detail
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}100Gemini 3 Flash · Google79.8s · 12,306 out | 78.2s · 11,552 out | 85.5s · 13,933 out
Reasoning · 12,110 tokens
**Understanding My Health Plan Details and Claim Processing**
Alright, I've been looking over the specifics of my health plan for the 2026 plan year, and I need to get a clear picture of how it all works, especially with the claims that have come in.
First off, the core financial parameters:
* My plan year runs from January 1st, 2026, to December 31st, 2026.
* For in-network services, my individual deductible is $1,500, and the family deductible is $3,000. Out-of-network, the individual deductible jumps to $3,000.
* The plan structure is "embedded," meaning individuals can meet their own deductibles, and the family deductible is also met once the total family contributions reach that amount, whichever happens first.
* My out-of-pocket maximum (OOPM) for in-network care is $6,000 individually and $12,000 for the family. Out-of-network, my individual OOPM is $12,000.
* It's important to note that my deductible balance for both in-network and out-of-network services accumulates into a single, combined balance. The threshold for this balance differs based on whether the service is in or out of network.
* Once the deductible is met, my coinsurance is 20% for in-network services and 40% for out-of-network.
* Copays, if any, do *not* count towards the deductible, but they *do* count towards the OOPM.
* All cost-sharing is based on the "allowed amount" for the service.
Now, let's look at my individual accumulators and how they stood before the recent claims:
* For myself (Subscriber A), my deductible balance was $900, and my OOPM accumulator was also $900.
* For my spouse (Subscriber B), their deductible balance was $0, and their OOPM was $0.
* The family accumulators reflected this: $900 towards the family deductible and $900 towards the family OOPM.
Now, let's walk through the claims and see how these numbers changed:
**Claim 1: Subscriber A, Out-of-Network (OON) Specialist Procedure**
* Allowed Amount: $2,400.00
* My current deductible balance for A was $900. The OON individual deductible is $3,000. This means I still needed $2,100 to meet this threshold ($3,000 - $900).
* The family deductible threshold is $3,000, and the current family balance was $900, so the family also needed $2,100.
* Since $2,100 was less than the $2,400 allowed amount, $2,100 was applied to meet my individual OON deductible and the family deductible.
* This left $300 of the allowed amount ($2,400 - $2,100).
* As it was an OON service, my coinsurance was 40% of this remaining $300, which is $120.
* My total responsibility for this claim was $2,100 (deductible) + $120 (coinsurance) = $2,220.
* The plan paid the remaining $180.
* **Accumulator Updates:**
* Subscriber A: Deductible balance is now $3,000 ($900 + $2,100). OOPM is now $3,120 ($900 + $2,220).
* Subscriber B: Deductible $0. OOPM $0.
* Family: Deductible is now $3,000 ($900 + $2,100) - *Family deductible met!* OOPM is now $3,120 ($900 + $2,220).
**Claim 2: Subscriber B, In-Network (IN) Outpatient Imaging**
* Allowed Amount: $1,300.00
* For Subscriber B, the individual IN deductible is $1,500. However, because the family deductible ($3,000) was met by Claim 1, B's deductible requirement is considered satisfied.
* Therefore, $0 was applied to the deductible for this claim.
* My coinsurance for IN services (after deductible) is 20%. So, 20% of $1,300 is $260.
* My responsibility for this claim was $260.
* The plan paid $1,040.
* **Accumulator Updates:**
* Subscriber A: Deductible $3,000. OOPM $3,120.
* Subscriber B: Deductible $0 (no amount applied). OOPM is now $260 ($0 + $260).
* Family: Deductible $3,000. OOPM is now $3,380 ($3,120 + $260).
**Claim 3: Subscriber A, In-Network (IN) Follow-up Procedure**
* Allowed Amount: $1,800.00
* My individual IN deductible threshold is $1,500. My current deductible balance for A is $3,000, which is well over this threshold. Therefore, A's individual IN deductible is met.
* $0 was applied to the deductible for this claim.
* My coinsurance for IN services is 20%. So, 20% of $1,800 is $360.
* My responsibility for this claim was $360.
* The plan paid $1,440.
* **Accumulator Updates:**
* Subscriber A: Deductible $3,000. OOPM is now $3,480 ($3,120 + $360).
* Subscriber B: Deductible $0. OOPM $260.
* Family: Deductible $3,000. OOPM is now $3,740 ($3,380 + $360).
**Claim 4: Subscriber A, Out-of-Network (OON) Diagnostic Study**
* Allowed Amount: $1,600.00
* My deductible balance for A is $3,000. The OON individual deductible threshold is $3,000. Since my balance meets or exceeds this threshold, my OON deductible is met.
* $0 was applied to the deductible for this claim.
* My coinsurance for OON services is 40%. So, 40% of $1,600 is $640.
* My responsibility for this claim was $640.
* The plan paid $960.
* **Accumulator Updates:**
* Subscriber A: Deductible $3,000. OOPM is now $4,120 ($3,480 + $640).
* Subscriber B: Deductible $0. OOPM $260.
* Family: Deductible $3,000. OOPM is now $4,380 ($3,740 + $640).
**Final Accumulator Status:**
* **Subscriber A:**
* Ending Deductible Balance: $3,000.00
* Ending OOPM Accumulator: $4,120.00
* **Subscriber B:**
* Ending Deductible Balance: $0.00
* Ending OOPM Accumulator: $260.00
* **Family:**
* Ending Deductible: $3,000.00 (Met)
* Ending OOPM: $4,380.00
For Claim 4 specifically:
* Member Responsibility: $640.00
* Plan Paid: $960.00
* Deductible Applied: $0.00
* Copay Amount: $0.00
* Coinsurance Amount: $640.00
* Ending Deductible for A: $3,000.00
* Ending OOPM for A: $4,120.00
* Ending Deductible for B: $0.00
* Ending OOPM for B: $260.00
* Ending Family Deductible: $3,000.00
* Ending Family OOPM: $4,380.00
This detailed breakdown helps me see exactly where I stand regarding my deductibles and out-of-pocket maximums throughout the year.
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Grader detail
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}Reasoning · 11,356 tokens
**My Thought Process on Adjudicating Health Claims**
Alright, let's break down these health plan details and claim adjudications. It's crucial to get these right, especially with an embedded deductible structure and varying in-network/out-of-network (OON) benefits. I'm going to walk through my thinking, step by step, as I process these claims for the 2026 plan year.
**Plan Year and Key Benefit Structures (2026-01-01 to 2026-12-31):**
First, I'm noting the core benefit levels.
* **Deductibles:**
* In-Network (IN): $1,500 Individual / $3,000 Family.
* Out-of-Network (OON): $3,000 Individual.
* **Deductible Structure:** This is key – it's *embedded*. This means individual deductibles apply, but the *family* deductible also has its own cap ($3,000 in this case). Importantly, *credits* from both IN and OON services contribute to a *single member deductible balance*. This balance is then compared against the relevant threshold (IN or OON) for the service.
* **Out-of-Pocket Maximum (OOPM):**
* Individual (IN): $6,000.
* Individual (OON): $12,000.
* Family (IN): $12,000. (Note: No Family OON OOPM specified, but our current totals won't hit this anyway).
* **Coinsurance:**
* IN: 20% Member / 80% Plan.
* OON: 40% Member / 60% Plan.
* **Copays:**
* PCP: $30, Specialist: $60, Urgent Care: $75, ER: $400.
* Crucially, copays *do not* count towards the deductible but *do* count towards the OOPM. This is a common, but sometimes tricky, feature.
**Initial Accumulator Status:**
Before any claims, I see the following:
* Member A (Subscriber): Deductible balance is $900, OOPM balance is $900.
* Member B (Spouse): Deductible balance is $0, OOPM balance is $0.
* Family: Deductible balance is $900, OOPM balance is $900.
* (This means A has already satisfied $900 of their individual deductible and OOPM, and this $900 also contributes to the family totals.)
**Adjudicating Claim 1 (Member A - Subscriber):**
* **Service:** Out-of-network specialist procedure.
* **Allowed Amount:** $2,400.00.
* **Analysis:** This is OON, so the $3,000 individual OON deductible threshold applies. Member A's current deductible balance is $900. The remaining amount needed to hit their *individual OON* deductible is $3,000 - $900 = $2,100.
* The plan rule states that "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." So, A's balance will increase.
* The rule also states, "The amount above [$3,000 OON] is the threshold that balance is measured against when the service is out-of-network."
* So, $2,100 of the allowed amount will be applied to A's deductible.
* **Deductible Applied:** $2,100.00.
* **Remaining Allowed Amount (after deductible):** $2,400 - $2,100 = $300.00.
* **Coinsurance (OON):** 40% of the remaining amount. $300 * 0.40 = $120.00.
* **Member Responsibility:** Deductible applied + Coinsurance = $2,100 + $120 = $2,220.00.
* **Plan Paid:** $300 * 0.60 = $180.00. (Note: Member Responsibility + Plan Paid = Allowed Amount: $2220 + $180 = $2400. This is a good check.)
* **Accumulator Updates:**
* A's Deductible Balance: $900 (initial) + $2,100 (applied) = $3,000.00.
* A's OOPM Balance: $900 (initial) + $2,220 (member responsibility) = $3,120.00.
* Family Deductible Balance: $900 (initial) + $2,100 (applied) = $3,000.00. (This has now met the family deductible threshold of $3,000.)
* Family OOPM Balance: $900 (initial) + $2,220 (member responsibility) = $3,120.00.
**Adjudicating Claim 2 (Member B - Spouse):**
* **Service:** In-network outpatient imaging.
* **Allowed Amount:** $1,300.00.
* **Analysis:** This is IN-network. Member B's individual IN deductible is $1,500. However, the *Family Deductible* is $3,000. My previous calculation showed that Claim 1 brought the *Family Deductible Balance* to $3,000.
* The rule for embedded deductibles states: "the family deductible is also satisfied once total family credits reach the family amount [3000], whichever comes first." Since the family deductible has been met, Member B does not need to meet their individual deductible for this claim.
* **Deductible Applied:** $0.00 (because family deductible is met).
* **Remaining Allowed Amount:** $1,300.00.
* **Coinsurance (IN):** 20% of the remaining amount. $1,300 * 0.20 = $260.00.
* **Member Responsibility:** Coinsurance = $260.00.
* **Plan Paid:** $1,300 * 0.80 = $1,040.00. (Check: $260 + $1040 = $1300.)
* **Accumulator Updates:**
* A's Deductible Balance: Remains $3,000.00.
* A's OOPM Balance: Remains $3,120.00.
* B's Deductible Balance: Remains $0.00 (B personally contributed $0 to the deductible this claim, even though the family total satisfied it).
* B's OOPM Balance: $0 (initial) + $260 (member responsibility) = $260.00.
* Family Deductible Balance: Remains $3,000.00 (capped).
* Family OOPM Balance: $3,120 (previous) + $260 (member responsibility) = $3,380.00.
**Adjudicating Claim 3 (Member A - Subscriber):**
* **Service:** In-network follow-up procedure.
* **Allowed Amount:** $1,800.00.
* **Analysis:** This is IN-network. Member A's individual IN deductible is $1,500. Their current deductible balance is $3,000. Since $3,000 is greater than $1,500, A's individual deductible is already satisfied. The family deductible is also already satisfied.
* **Deductible Applied:** $0.00.
* **Remaining Allowed Amount:** $1,800.00.
* **Coinsurance (IN):** 20% of the remaining amount. $1,800 * 0.20 = $360.00.
* **Member Responsibility:** Coinsurance = $360.00.
* **Plan Paid:** $1,800 * 0.80 = $1,440.00. (Check: $360 + $1440 = $1800.)
* **Accumulator Updates:**
* A's Deductible Balance: Remains $3,000.00.
* A's OOPM Balance: $3,120 (previous) + $360 (member responsibility) = $3,480.00.
* B's Deductible Balance: Remains $0.00.
* B's OOPM Balance: Remains $260.00.
* Family Deductible Balance: Remains $3,000.00.
* Family OOPM Balance: $3,380 (previous) + $360 (member responsibility) = $3,740.00.
**Adjudicating Claim 4 (Member A - Subscriber):**
* **Service:** Out-of-network diagnostic study.
* **Allowed Amount:** $1,600.00.
* **Analysis:** This is OON. Member A's current deductible balance is $3,000. The OON individual deductible threshold is $3,000. Since A's balance ($3,000) meets or exceeds the OON threshold ($3,000), the deductible is satisfied for this claim.
* **Deductible Applied:** $0.00.
* **Remaining Allowed Amount:** $1,600.00.
* **Coinsurance (OON):** 40% of the remaining amount. $1,600 * 0.40 = $640.00.
* **Member Responsibility:** Coinsurance = $640.00.
* **Plan Paid:** $1,600 * 0.60 = $960.00. (Check: $640 + $960 = $1600.)
* **Accumulator Updates:**
* A's Deductible Balance: Remains $3,000.00.
* A's OOPM Balance: $3,480 (previous) + $640 (member responsibility) = $4,120.00.
* B's Deductible Balance: Remains $0.00.
* B's OOPM Balance: Remains $260.00.
* Family Deductible Balance: Remains $3,000.00.
* Family OOPM Balance: $3,740 (previous) + $640 (member responsibility) = $4,380.00.
**Final Output for Claim 4:**
Based on the adjudication for Claim 4:
* `member_responsibility`: $640.00
* `plan_paid`: $960.00
* `deductible_applied`: $0.00
* `copay_amount`: $0.00 (No copay service for this claim type)
* `coinsurance_amount`: $640.00
**Ending Accumulators After All Claims:**
* `ending_deductible_a`: $3,000.00
* `ending_oopm_a`: $4,120.00
* `ending_deductible_b`: $0.00
* `ending_oopm_b`: $260.00
* `ending_family_deductible`: $3,000.00
* `ending_family_oopm`: $4,380.00
This comprehensive walk-through, paying close attention to the embedded deductible rules and the distinction between individual and family balances, along with IN/OON variations, ensures an accurate adjudication. The key was understanding how credits contribute to a single balance, and how that balance is compared against the appropriate threshold, while also tracking the separate OOPM accumulations.
json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "4120.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3000.00",
"ending_family_oopm": "4380.00"
}
Grader detail
json{
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{
"field": "member_responsibility",
"want": 640,
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"ok": true,
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},
{
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"want": 960,
"got": "960.00",
"ok": true,
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{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
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{
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"ok": true,
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{
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{
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"want": 3000,
"got": "3000.00",
"ok": true,
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{
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"got": "4380.00",
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{
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"want": 3000,
"got": "3000.00",
"ok": true,
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},
{
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"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
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{
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"want": 260,
"got": "260.00",
"ok": true,
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}
],
"fabricated": false,
"abstained": false
}Reasoning · 13,737 tokens
Here are my thoughts as I worked through this:
**Deconstructing the Bluebonnet PPO 1500 Plan and Processing Claims**
Alright, let's break down this Bluebonnet PPO 1500 plan for 2026. I need to get a firm grasp on the deductible and out-of-pocket maximums, both for in-network (IN) and out-of-network (OON) services, and understand how the "embedded" structure works.
Here are the key figures I'm noting:
* **Deductibles:**
* Individual IN: \$1500
* Family IN: \$3000
* Individual OON: \$3000
* **Out-of-Pocket Maximums (OOPM):**
* Individual IN: \$6000
* Family IN: \$12000
* Individual OON: \$12000
* **Coinsurance:**
* IN: 20% member / 80% plan (after deductible)
* OON: 40% member / 60% plan (after deductible)
* **Copays:** Primary (\$30), Specialist (\$60), Urgent (\$75), ER (\$400, waived if admitted), Generic Retail (\$15). Crucially, copays *don't* credit the deductible but *do* credit the OOPM.
* **Structure:** It's an "embedded" plan. This means an individual can meet their individual deductible, and the family deductible is also met when the total family credits reach that amount, whichever occurs first.
* **Deductible Balance:** A critical detail is that "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." This means all deductible payments, regardless of network, contribute to one running total for each member.
* **OON Deductible Threshold:** For OON services, "the amount above [the individual OON deductible, \$3000] is the threshold that balance is measured against." This means if a member hasn't met their \$3000 OON deductible, they'll pay towards it up to that \$3000 mark before coinsurance kicks in for OON services.
Now, I need to track the initial accumulators:
* **Member A:** Deductible \$900, OOPM \$900.
* **Member B:** Deductible \$0, OOPM \$0.
* **Family:** Deductible \$900, OOPM \$900.
Let's process the claims step-by-step, carefully updating these accumulators after each one.
**Claim 1: Out-of-Network Specialist Procedure**
* **Service:** OON Specialist Procedure
* **Allowed Amount:** \$2400
* **Network:** Out-of-network
* **Member:** A
* **A's starting deductible balance:** \$900
* **A's OON deductible threshold:** \$3000
* **Remaining A OON deductible needed:** \$3000 - \$900 = \$2100.
* **Amount applied to A's deductible:** Since the allowed amount (\$2400) is more than what's needed to meet the deductible (\$2100), I'll apply the full \$2100 to A's deductible.
* **Remaining allowed amount for coinsurance:** \$2400 - \$2100 = \$300.
* **OON Coinsurance:** Member pays 40%. So, 40% of \$300 = \$120.
* **Member Responsibility (Claim 1):** \$2100 (deductible) + \$120 (coinsurance) = \$2220.
* **Plan Paid (Claim 1):** \$2400 (allowed) - \$2220 (member resp) = \$180.
* **Updating Accumulators (A):**
* A Deductible: \$900 (start) + \$2100 (applied) = \$3000. (A has now met their individual OON deductible).
* A OOPM: \$900 (start) + \$2220 (member resp) = \$3120. (Below A's individual OON OOPM of \$12000).
* **Updating Accumulators (Family):**
* Family Deductible: \$900 (start) + \$2100 (A's contribution) = \$3000. (The family IN deductible of \$3000 is met because A's contribution, even though OON, counts towards the single deductible balance and the family total).
* Family OOPM: \$900 (start) + \$2220 (A's resp) = \$3120.
**Claim 2: In-Network Outpatient Imaging**
* **Service:** In-network outpatient imaging
* **Allowed Amount:** \$1300
* **Network:** In-network
* **Member:** B
* **B's starting deductible:** \$0.
* **Family deductible status:** \$3000 (already met by A's contribution in Claim 1).
* **Impact of Family Deductible:** Since the family deductible is met, B's individual deductible is also satisfied for in-network services.
* **In-network Coinsurance (after deductible):** Member pays 20%. So, 20% of \$1300 = \$260.
* **Member Responsibility (Claim 2):** \$260.
* **Plan Paid (Claim 2):** \$1300 - \$260 = \$1040.
* **Updating Accumulators (B):**
* B Deductible: \$0. (No personal payment towards deductible here as the family limit was reached).
* B OOPM: \$0 (start) + \$260 (member resp) = \$260.
* **Updating Accumulators (Family):**
* Family Deductible: \$3000 (already met).
* Family OOPM: \$3120 (previous total) + \$260 (B's resp) = \$3380.
**Claim 3: In-Network Follow-up Procedure**
* **Service:** In-network follow-up procedure
* **Allowed Amount:** \$1800
* **Network:** In-network
* **Member:** A
* **A's starting deductible balance:** \$3000.
* **A's IN deductible threshold:** \$1500.
* **Deductible Status:** A's deductible is clearly met (\$3000 > \$1500).
* **In-network Coinsurance:** Member pays 20%. So, 20% of \$1800 = \$360.
* **Member Responsibility (Claim 3):** \$360.
* **Plan Paid (Claim 3):** \$1800 - \$360 = \$1440.
* **Updating Accumulators (A):**
* A Deductible: \$3000 (no change, already met).
* A OOPM: \$3120 (previous total) + \$360 (member resp) = \$3480.
* **Updating Accumulators (Family):**
* Family Deductible: \$3000 (no change).
* Family OOPM: \$3380 (previous total) + \$360 (A's resp) = \$3740.
**Claim 4: Out-of-Network Diagnostic Study**
* **Service:** Out-of-network diagnostic study
* **Allowed Amount:** \$1600
* **Network:** Out-of-network
* **Member:** A
* **A's starting deductible balance:** \$3000.
* **A's OON deductible threshold:** \$3000.
* **Deductible Status:** A's deductible is met (\$3000 = \$3000).
* **OON Coinsurance:** Member pays 40%. So, 40% of \$1600 = \$640.
* **Member Responsibility (Claim 4):** \$640.
* **Plan Paid (Claim 4):** \$1600 - \$640 = \$960.
* **Updating Accumulators (A):**
* A Deductible: \$3000 (no change, already met).
* A OOPM: \$3480 (previous total) + \$640 (member resp) = \$4120. (Still below A's individual OON OOPM of \$12000).
* **Updating Accumulators (Family):**
* Family Deductible: \$3000 (no change).
* Family OOPM: \$3740 (previous total) + \$640 (A's resp) = \$4380. (Still below the family IN OOPM of \$12000).
**Final Accumulators:**
After processing all claims, here are the ending accumulators:
* **Member A:**
* Ending Deductible: \$3000.00
* Ending OOPM: \$4120.00
* **Member B:**
* Ending Deductible: \$0.00
* Ending OOPM: \$260.00
* **Family:**
* Ending Deductible: \$3000.00
* Ending OOPM: \$4380.00
**Summary of Claim 4 Calculations:**
For Claim 4, the specific outputs are:
* Member Responsibility: \$640.00
* Plan Paid: \$960.00
* Deductible Applied: \$0.00 (since the deductible was already met)
* Copay Amount: \$0.00 (no copay applicable here)
* Coinsurance Amount: \$640.00
json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "4120.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3000.00",
"ending_family_oopm": "4380.00"
}
Grader detail
json{
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{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
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{
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"got": "960.00",
"ok": true,
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},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
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{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
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},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
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},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3000.00",
"ok": true,
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},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4380.00",
"ok": true,
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{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
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},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
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}
],
"fabricated": false,
"abstained": false
}100Kimi K3 · Moonshot84.3s · 3,140 out | 86.1s · 2,333 out | 137.2s · 4,951 out
Reasoning · 2,984 tokens
Let me work through this carefully.
Plan: Bluebonnet PPO 1500, plan year 2026.
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00
- Embedded structure
- Out-of-network individual deductible: 3000.00
- Key rule: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above [3000.00] is the threshold that balance is measured against when the service is out-of-network."
So there's a single deductible balance per member. For in-network services, the threshold is 1500 individual / 3000 family. For out-of-network services, the threshold is 3000 individual.
Hmm, how does the family deductible interact with out-of-network? The document says family deductible in-network 3000.00. The out-of-network is individual 3000.00. There's no family OON deductible listed. The single balance is measured against 3000 when the service is OON.
OOPM:
- Individual in-network: 6000.00
- Family in-network: 12000.00
- Individual out-of-network: 12000.00
- Once a member reaches the OOPM, plan pays 100%.
Question: is there a single OOPM accumulator too? The document only explicitly says deductible credits accumulate to a single member deductible balance. For OOPM, it lists individual (in-network) 6000, family 12000, individual OON 12000. Copays always credit the OOPM.
Hmm. The accumulator starts: A deductible 900, OOPM 900. Family deductible 900, OOPM 900.
Let me think about how OON cost share credits OOPM. The document doesn't explicitly say there's a single OOPM balance. But it gives an individual OON OOPM of 12000. Similar logic might apply: a single OOPM balance measured against 6000 in-network or 12000 out-of-network? Or separate accumulators?
Actually, let's think. The starting accumulators give one deductible number and one OOPM number per member — suggesting single balances. The task asks for "ending_deductible_a" (one number) and "ending_oopm_a" (one number). So single accumulators.
For the deductible: single balance, threshold 1500 when service is IN, 3000 when service is OON.
For the OOPM: the family says OOPM individual in-network 6000, OON 12000. Presumably single balance measured against 6000 when in-network... but does the OOPM "reached" status depend on the service network? Typically once you hit the OOPM, plan pays 100% for covered services. The document says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year."
Hmm, which OOPM? There are two thresholds: 6000 (IN) and 12000 (OON). The deductible rule explicitly describes the single-balance mechanism; the OOPM section doesn't. But given the harness's design, likely the same mechanism: single OOPM balance, measured against 6000 when service is in-network, 12000 when out-of-network. Actually wait — "Individual (out-of-network) 12000.00" — that's the threshold for out-of-network services.
Let me just process the claims and see whether OOPM comes into play.
Starting:
- A: deductible balance 900.00, OOPM balance 900.00
- B: 0/0
- Family: deductible 900.00, OOPM 900.00
**Claim 1 — 2026-05-05 — A — Out-of-network specialist procedure. Allowed 2400.00.**
OON: deductible threshold for A is 3000.00 (single balance measured against 3000 when service is OON).
A's current deductible balance: 900.00. Remainder to 3000: 2100.00.
Family deductible: family total 900.00; family threshold... For OON, is there a family threshold? Only individual OON 3000 listed. The family deductible 3000 in-network. Embedded structure: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
The family deductible credit: deductible applied on claims credits both member and family. Family deductible is 3000 (in-network). Hmm, but for OON services, what's the family threshold? Not specified. The family total starts at 900.
Let me think about how the harness intends this. "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." So deductible_applied = min(allowed, individual remainder, family remainder).
For Claim 1 (OON): individual remainder = 3000 - 900 = 2100. Family remainder = 3000 - 900 = 2100. So deductible applied = min(2400, 2100, 2100) = 2100.
Wait, but does the family deductible apply to OON services? The plan says in-network family deductible 3000, and "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." This suggests member-level single balance. The family deductible — presumably also a single balance? The starting family deductible is 900, matching A's 900. I'll treat the family deductible as a single accumulator too, threshold 3000.
So Claim 1:
- Allowed 2400.00
- Deductible applied: min(2400, 3000-900 [individual OON remainder], 3000-900 [family remainder]) = 2100.00
- After deductible: A's balance = 900+2100 = 3000 → meets OON individual threshold (3000). Family balance = 900+2100 = 3000 → family deductible satisfied too.
- Remaining allowed: 2400 - 2100 = 300.00
- Coinsurance OON: member 40% of 300 = 120.00; plan 60% = 180.00.
- Member responsibility: 2100 + 120 = 2220.00
- Plan paid: 180.00
- Check: 2220 + 180 = 2400 ✓
OOPM: member cost share 2220 credits OOPM. A's OOPM: 900 + 2220 = 3120.00. Family OOPM: 900 + 2220 = 3120.00.
Is A's OOPM reached? OON threshold 12000, no. IN threshold 6000, no.
**Claim 2 — 2026-05-21 — B — In-network outpatient imaging. Allowed 1300.00.**
B's deductible balance: 0. Individual IN threshold 1500 → remainder 1500.
Family deductible: 3000 balance (after claim 1). Family threshold 3000 → remainder 0. Family deductible satisfied.
Embedded: B's deductible applied = min(allowed 1300, individual remainder 1500, family remainder 0) = 0.
So B pays no deductible. Family deductible already met, so plan pays coinsurance.
Coinsurance IN: member 20% of 1300 = 260.00; plan 80% = 1040.00.
- Member responsibility: 260.00
- Plan paid: 1040.00
- deductible_applied: 0.00
Accumulators:
- B deductible: 0 (no deductible credit).
- B OOPM: 0 + 260 = 260.00
- Family deductible: 3000.00 (unchanged)
- Family OOPM: 3120 + 260 = 3380.00
Wait — does B's own deductible matter at all? Since family deductible is met, embedded structure means B's deductible is satisfied via family. Yes, deductible_applied = 0.
**Claim 3 — 2026-06-14 — A — In-network follow-up procedure. Allowed 1800.00.**
A's deductible balance: 3000.00. IN individual threshold 1500 — already exceeded (3000 ≥ 1500), so satisfied. Family satisfied. Deductible applied = 0.
Coinsurance IN: member 20% of 1800 = 360.00; plan 1440.00.
Check OOPM: A's OOPM before = 3120. IN individual OOPM = 6000. Member cost share 360 → 3120 + 360 = 3480 < 6000. Not reached. So member pays 360.
- Member responsibility: 360.00
- Plan paid: 1440.00
- A OOPM: 3480.00
- Family OOPM: 3380 + 360 = 3740.00
- A deductible: 3000.00 (no change)
**Claim 4 — 2026-07-08 — A — Out-of-network diagnostic study. Allowed 1600.00.**
OON service. A's deductible balance: 3000.00. OON threshold 3000 → satisfied (3000 ≥ 3000). Deductible applied = 0.
Coinsurance OON: member 40% of 1600 = 640.00; plan 60% = 960.00.
Check OOPM: A's OOPM = 3480. OON individual OOPM = 12000 — not reached. Also IN 6000 — not reached. So member pays 640.
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00 (no copay for this service; it's a diagnostic study, OON — copays listed are for office visits, urgent care, ER, pharmacy)
- coinsurance_amount: 640.00
Ending accumulators:
- A deductible: 3000.00
- A OOPM: 3480 + 640 = 4120.00
- B deductible: 0.00
- B OOPM: 260.00
- Family deductible: 3000.00
- Family OOPM: 3740 + 640 = 4380.00
Wait — let me double-check whether OON cost share counts toward the in-network OOPM and vice versa. The document says "Copays do NOT credit the deductible. Copays always credit the out-of-pocket maximum." For OOPM accumulation across networks, it's silent, but the single-balance treatment for deductibles and the single accumulator fields imply single OOPM balances too. Also, the starting accumulators show one OOPM number. I'll go with single OOPM balance.
One more consideration on Claim 1: should the deductible applied consider that A's single balance is 900 and the OON threshold is 3000? Yes per the document: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." "The amount above" refers to the 3000 out-of-network individual deductible. So remainder = 3000 - 900 = 2100.
Family remainder: family deductible balance 900, family threshold 3000 → 2100. Embedded: lesser of individual remainder and family remainder → 2100.
Allowed 2400 > 2100, so deductible 2100, then 300 subject to coinsurance 40% = 120.
Claim 1 totals: member 2220, plan 180.
Now Claim 4 check: member 640, plan 960, sum 1600 ✓.
Ending accumulators:
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
Hmm, wait. Let me reconsider whether the family deductible accumulator can exceed... it's at exactly 3000, satisfied. Fine.
Also reconsider Claim 2: does B's imaging count as a service with a copay? No, imaging is subject to deductible/coinsurance. Deductible satisfied via family. Member 20% = 260. Correct.
Reconsider whether B's OON... no, Claim 2 is in-network.
One nuance: after Claim 1, A's deductible balance is 3000, which satisfies both the IN individual (1500) and OON (3000) thresholds, and family (3000). So Claims 3 and 4 have no deductible.
OOPM checks: A's OOPM max relevant threshold: when service is IN, 6000; OON, 12000. Never reached. Family OOPM 12000 not reached.
Numbers:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
Output as numbers with two decimals. JSON numbers — 640.00 is fine as 640.00 (JSON allows trailing zeros). I'll write them as numbers with two decimals.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 2,177 tokens
Let me carefully work through this.
Plan: Bluebonnet PPO 1500
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00
- Structure: EMBEDDED — individual satisfies individual deductible on their own; family satisfied once total family credits reach family amount.
- Out-of-network individual deductible: 3000.00. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above (3000.00) is the threshold measured against when the service is out-of-network.
So there's a single deductible balance per member. When the service is in-network, the threshold is 1500; when out-of-network, the threshold is 3000.
Hmm, how does this work with embedded family deductible? Family deductible: 3000.00 in-network. The family accumulator total. For OON services... the plan only gives OON individual deductible 3000 and OON OOPM 12000. Family OON deductible isn't specified. The family total deductible presumably accumulates all credits (IN + OON) toward 3000? The document says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." That's about the member deductible. For family, presumably all credits accumulate to the family deductible too (the family total deductible accumulator).
OOPM: Individual in-network 6000, family 12000, individual OON 12000. Copays always credit OOPM. Member cost share credits OOPM. Does OON cost share credit the in-network OOPM? The plan gives separate OON OOPM (12000 individual). Typically OON cost share credits OON OOPM, not IN OOPM. But the deductible explicitly says single balance. The OOPM section doesn't say single balance. Hmm.
This is the tricky part. The harness expects a determinate answer. Let me think about what the intended interpretation is.
Deductible: single member balance, threshold depends on network of service (1500 IN, 3000 OON). Family deductible accumulator: sum of all family credits; threshold 3000 (in-network family amount; no OON family amount given).
OOPM: separate IN and OON individual OOPMs (6000 IN, 12000 OON). Family OOPM 12000. Which accumulator does OON cost share credit? Probably a separate OON OOPM balance. But the question asks for ending_oopm_a — presumably a single number. Hmm.
Maybe the intended interpretation: like the deductible, there's a single OOP balance, measured against the threshold based on the service network. But the document doesn't say that for OOPM. Actually, let's reconsider: maybe the OOPM accumulator is single too (member's total cost share), and the threshold is 6000 for IN services and 12000 for OON services. The family OOPM is 12000.
The starting accumulators: A deductible 900.00, OOP 900.00. So A has 900 credited to both. Family 900/900.
Let me adjudicate each claim under the "single balance with network-dependent threshold" interpretation, which mirrors the deductible rule. Actually for OOPM, the document doesn't specify single balance; it gives individual OON 12000. Common plan design: IN and OON accumulate separately. But then ending_oopm_a would be ambiguous. Given the harness wants one number, likely the intended model is a single OOP balance with threshold depending on the service's network, analogous to the deductible. Hmm, but actually the deductible rule explicitly states single balance; the OOPM section doesn't. Let me think about what actually happens numerically to see if it matters.
Initial: A ded 900, A oop 900. B ded 0, oop 0. Family ded 900, oop 900.
Claim 1 — A — OON specialist procedure — allowed 2400.00.
A's deductible balance: 900. OON threshold: 3000. So deductible not met. Remaining to OON threshold: 2100.
Embedded: member's deductible applied = min(individual remainder, family remainder). Family remainder: 3000 - 900 = 2100. Individual remainder (OON threshold): 3000 - 900 = 2100. So deductible applied = min(2100, 2100) = 2100.
Allowed 2400. Deductible applied 2100 (member pays 2100 at allowed rate). Remaining 300 subject to coinsurance OON 40% member: 120 member, 180 plan.
Member responsibility claim 1: 2100 + 120 = 2220. Plan paid: 180.
After claim 1: A ded balance: 900 + 2100 = 3000. Family ded: 900 + 2100 = 3000 (met). A oop: 900 + 2220 = 3120. Family oop: 900 + 2220 = 3120.
Claim 2 — B — IN imaging — allowed 1300.
B deductible balance 0, IN threshold 1500. Individual remainder 1500. Family remainder: family ded 3000 - 3000 = 0. Embedded: deductible satisfied by lesser of individual remainder and family remainder → family remainder is 0, so B's deductible is considered met (family deductible satisfied). So no deductible applied.
Coinsurance IN 20%: member 260, plan 1040.
Member responsibility: 260. Plan paid: 1040.
After: B ded balance: 0 (no deductible credit; the 260 is coinsurance). B oop: 260. Family ded: 3000. Family oop: 3120 + 260 = 3380.
Claim 3 — A — IN follow-up procedure — allowed 1800.
A ded balance 3000. IN threshold 1500 — met. Family met. No deductible.
Coinsurance 20%: member 360, plan 1440.
After: A oop: 3120 + 360 = 3480. Family oop: 3380 + 360 = 3740. A ded: 3000. Family ded 3000.
Wait — but hold on: A's deductible balance is 3000, which exceeds the IN threshold 1500. Fine, met either way.
Claim 4 — A — OON diagnostic study — allowed 1600.
A ded balance 3000. OON threshold 3000 — met (balance equals threshold). Family met. Deductible applied: 0.
Coinsurance OON 40%: member 640, plan 960.
Member responsibility: 640. Plan paid: 960.
Copay: 0 (procedure, not an office visit; no copay applies).
After: A oop: 3480 + 640 = 4120. Family oop: 3740 + 640 = 4380.
A ded: 3000. B ded: 0. Family ded: 3000.
Check OOPM: A's OOP balance 4120 < OON OOPM 12000 and < IN 6000. Family 4380 < 12000. No OOPM caps hit.
Now, does the OON cost share credit the same OOP accumulator? If separate OON OOP accumulator existed, ending_oopm_a would be ambiguous. Since the question asks for one number, and the deductible rule shows the plan's style of a single balance, I'll report the single combined OOP: A 4120.
Hmm, but wait — is the OOP accumulator for A measured against the in-network 6000 or OON 12000? It doesn't matter for the result since no cap is hit.
Let me double-check Claim 1's deductible application under embedded rules: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Individual remainder for A on an OON service: threshold 3000, balance 900, remainder 2100. Family remainder: 3000 - 900 = 2100. Lesser = 2100. Applied deductible 2100. Yes.
Coinsurance claim 1: (2400 - 2100) * 0.40 = 120. Member total 2220. Plan paid 2400 - 2220 = 180. ✓.
Claim 2: family remainder 0 → deductible met → member pays 20% of 1300 = 260. Plan 1040. ✓.
Claim 3: A's deductible met (3000 ≥ 1500). Member 20% of 1800 = 360. Plan 1440. ✓.
Claim 4: A's deductible balance 3000 ≥ OON threshold 3000 → met. Member 40% of 1600 = 640. Plan 960. ✓.
Ending accumulators:
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
Claim 4 components:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
Check: 640 + 960 = 1600 ✓. deductible_applied + copay + coinsurance = 0 + 0 + 640 = 640 = member responsibility ✓.
Output the JSON with exactly the required keys. Numbers as... "Numbers are plain, two decimal places" — should they be JSON numbers or strings? The output contract says report dollar amounts as plain numbers with two decimals. JSON numbers like 640.00 are fine (though JSON would parse as 640, the textual representation with two decimals is what's asked). I'll emit them as numbers with two decimal places.
json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 4,790 tokens
Let me carefully work through this problem.
Plan: Bluebonnet PPO 1500
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The threshold that balance is measured against when the service is out-of-network is 3000.00 (the OON individual deductible). When in-network, threshold is 1500.00.
Wait, let me re-read: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
"The amount above" refers to "Out-of-network (individual) 3000.00". So when the service is out-of-network, the member's single deductible balance is measured against the 3000.00 threshold. When in-network, it's measured against 1500.00.
Hmm, but the family deductible is 3000.00 in-network. What about family OON? The document only gives Family in-network 3000.00. It doesn't give a family OON deductible. Let me think about how this works.
Actually, the deductible section:
- Individual (in-network): 1500.00
- Family (in-network): 3000.00
- Structure: EMBEDDED
- Out-of-network (individual): 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
So each member has ONE deductible balance (combining in and out of network credits). The threshold depends on the service network: for an in-network service, the individual threshold is 1500; for an out-of-network service, the individual threshold is 3000.
But the family deductible: Family (in-network) 3000.00. There's no family OON deductible given. Hmm. Under embedded structure, a member satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
Let me reconsider. The family deductible of 3000.00 — is there an OON family threshold? Not specified. I think the family deductible is 3000.00 regardless (it's the "Family (in-network)" but the credits accumulate... hmm).
Actually, let me reconsider the whole structure. This is a bit unusual. Let me parse very carefully.
"In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." — So for member A, there's one deductible accumulator that gets credited by both in-network and out-of-network cost share that applies to deductible.
"The amount above is the threshold that balance is measured against when the service is out-of-network." — "The amount above" = 3000.00 (the out-of-network individual amount). So when adjudicating an out-of-network service, we compare A's single balance against 3000.00 to see if the deductible is satisfied. When adjudicating an in-network service, we compare against 1500.00.
Now what about the family deductible? The family deductible is 3000.00 (in-network). Under embedded: an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
Hmm, but for out-of-network services, what's the family threshold? Not given. I think we should treat the family deductible threshold as 3000.00 for all services (since only one family amount is given). Actually wait — but the individual OON threshold is 3000 which equals the family in-network threshold of 3000. This creates an interesting interaction.
Let me just process claim by claim.
Starting accumulators (before Claim 1):
- A: deductible 900.00, OOP 900.00
- B: deductible 0.00, OOP 0.00
- Family: deductible 900.00, OOP 900.00
Note: A's deductible balance is 900.00 already. This is the SINGLE balance (combining in and out of network). Good.
**Claim 1 — 2026-05-05 — A (subscriber) — Out-of-network specialist procedure**
- Network: Out-of-network
- Allowed: 2400.00
For OON service, A's deductible threshold = 3000.00. A's current deductible balance = 900.00. Remaining to satisfy individual deductible (OON threshold) = 3000 - 900 = 2100.00.
Family deductible: current 900.00, threshold 3000.00, remaining = 2100.00.
Under embedded structure, member A's deductible is satisfied by the lesser of individual remainder and family remainder. Individual remainder (measured against OON threshold since service is OON) = 2100. Family remainder = 3000 - 900 = 2100. So lesser = 2100.
So deductible applied on this claim = min(allowed, lesser remainder) = min(2400, 2100) = 2100.00.
After deductible applied: A's deductible balance = 900 + 2100 = 3000.00. Family deductible = 900 + 2100 = 3000.00.
Remaining allowed after deductible = 2400 - 2100 = 300.00.
Now is the deductible satisfied? A's balance = 3000. For OON threshold (3000), yes satisfied. Family deductible = 3000, satisfied.
So the remaining 300 is subject to coinsurance. OON coinsurance: 40% member / 60% plan.
Member coinsurance = 40% of 300 = 120.00. Plan = 60% of 300 = 180.00.
Member responsibility for claim 1 = deductible applied + coinsurance = 2100 + 120 = 2220.00.
Plan paid = allowed - member responsibility = 2400 - 2220 = 180.00.
Check: member_responsibility + plan_paid = 2220 + 180 = 2400 = allowed. Good.
OOP credit: deductible applied and coinsurance both credit OOP. (Copays credit OOP but not deductible; here no copay.) So OOP for A increases by member responsibility = 2220. A's OOP = 900 + 2220 = 3120.00. Family OOP = 900 + 2220 = 3120.00.
Wait — but does the deductible credit count toward OOP? Yes, deductible is member cost share, counts toward OOPM. The document says "Copays do NOT credit the deductible. Copays always credit the out-of-pocket maximum." It implies deductible and coinsurance credit OOPM (standard). OOPM is "the ceiling on member cost share." Member cost share includes deductible, coinsurance, copays. So yes, all member responsibility credits OOPM.
After Claim 1:
- A: deductible 3000.00, OOP 3120.00
- B: deductible 0.00, OOP 0.00
- Family: deductible 3000.00, OOP 3120.00
**Claim 2 — 2026-05-21 — B (spouse) — In-network outpatient imaging**
- Network: In-network
- Allowed: 1300.00
For B, in-network service. B's individual deductible threshold (in-network) = 1500.00. B's current deductible balance = 0.00. Individual remainder = 1500.
Family deductible: current = 3000.00, threshold = 3000.00. Family deductible is ALREADY satisfied (3000 >= 3000). So family remainder = 0.
Under embedded: B's deductible is satisfied by the lesser of individual remainder and family remainder. Lesser of (1500, 0) = 0. So deductible applied = 0!
Wait, that's the key embedded logic. The family deductible is already met (3000 reached after claim 1). So for any family member, the deductible is considered satisfied because the family deductible is met. Under embedded structure, once the family deductible is satisfied, the plan pays for all members (no more deductible).
Let me re-read: "EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
And the family task rules: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
So for B on Claim 2: individual remainder = 1500 (in-network threshold), family remainder = 3000 - 3000 = 0. Lesser = 0. So deductible applied = 0. B's deductible is treated as satisfied (because family is satisfied).
So entire allowed 1300 is subject to coinsurance (in-network): 20% member / 80% plan.
Member coinsurance = 20% of 1300 = 260.00. Plan = 80% = 1040.00.
Member responsibility claim 2 = 0 deductible + 260 coinsurance = 260.00.
Plan paid = 1300 - 260 = 1040.00.
B's accumulators: deductible — does B's deductible balance get credited? Deductible applied = 0, so B's deductible balance stays 0.00. But B's OOP increases by 260. B OOP = 0 + 260 = 260.00.
Family: deductible stays 3000.00 (no deductible applied). Family OOP = 3120 + 260 = 3380.00.
Hmm wait, but should B's deductible balance increase? Since deductible applied is 0, no. B's deductible accumulator remains 0.00. That's fine because the family deductible is already met; B doesn't need to satisfy individual deductible.
Actually, let me reconsider whether B's individual deductible should be considered "satisfied" for ending_deductible_b reporting. The question asks for ending_deductible_b — that's the accumulator value (the running YTD total of deductible credits). B had 0 deductible applied, so ending_deductible_b = 0.00. I'll report the accumulator, not a "satisfied" flag. The key name is ending_deductible_b, parallel to ending_deductible_a which is the accumulator. So report accumulator values.
After Claim 2:
- A: deductible 3000.00, OOP 3120.00
- B: deductible 0.00, OOP 260.00
- Family: deductible 3000.00, OOP 3380.00
**Claim 3 — 2026-06-14 — A (subscriber) — In-network follow-up procedure**
- Network: In-network
- Allowed: 1800.00
For A, in-network service. A's individual deductible threshold (in-network) = 1500. A's current deductible balance = 3000. Individual remainder = 1500 - 3000 = negative → 0 (already satisfied). Family remainder = 3000 - 3000 = 0. Lesser = 0. Deductible applied = 0.
So entire 1800 subject to in-network coinsurance: 20% member.
But wait — check OOPM. A's OOP = 3120.00. Individual in-network OOPM = 6000. Not reached. Family OOPM = 12000, family OOP = 3380, not reached. So normal coinsurance.
Member coinsurance = 20% of 1800 = 360.00. Plan = 1440.00.
Member responsibility claim 3 = 360.00. Plan paid = 1440.00.
A's OOP = 3120 + 360 = 3480.00. A's deductible stays 3000.00.
Family OOP = 3380 + 360 = 3740.00. Family deductible stays 3000.00.
After Claim 3:
- A: deductible 3000.00, OOP 3480.00
- B: deductible 0.00, OOP 260.00
- Family: deductible 3000.00, OOP 3740.00
**Claim 4 — 2026-07-08 — A (subscriber) — Out-of-network diagnostic study**
- Network: Out-of-network
- Allowed: 1600.00
For A, out-of-network service. A's deductible threshold (OON) = 3000. A's balance = 3000. Remainder = 0. Family remainder = 0. Deductible applied = 0.
Check OOPM: A's OOP = 3480. OON individual OOPM = 12000. Not reached. In-network individual OOPM = 6000. Hmm — which OOPM threshold applies for an OON service?
The plan gives:
- OOPM Individual (in-network): 6000
- OOPM Family (in-network): 12000
- OOPM Individual (out-of-network): 12000
There's no separate family OON OOPM given; family OOPM is 12000. For an out-of-network service, the relevant individual OOPM threshold is 12000. A's OOP accumulator — is it a single accumulator too? The plan doesn't explicitly say OOP accumulates to a single balance across in/out network, but it says "Once a member reaches the out-of-pocket maximum the plan pays 100%." The starting accumulator gives A a single out-of-pocket value (900). And the family has a single out-of-pocket total. So OOP is tracked as a single member accumulator and single family accumulator. The threshold measured against depends on network: for OON, individual threshold = 12000; for in-network, = 6000. Family threshold = 12000.
A's OOP = 3480, well below 6000 and 12000. Family OOP = 3740 below 12000. So no OOPM effect.
So Claim 4: deductible applied = 0. Subject to OON coinsurance 40% member / 60% plan.
Member coinsurance = 40% of 1600 = 640.00. Plan = 60% = 960.00.
member_responsibility (Claim 4) = 0 + 640 = 640.00.
plan_paid = 1600 - 640 = 960.00.
deductible_applied = 0.00.
copay_amount = 0.00 (it's a diagnostic study, not an office visit/ER/urgent care/pharmacy; no copay applies).
coinsurance_amount = 640.00.
Check: 640 + 960 = 1600 = allowed. Good.
Ending accumulators after Claim 4:
- A: deductible stays 3000.00. OOP = 3480 + 640 = 4120.00.
- B: deductible 0.00, OOP 260.00.
- Family: deductible 3000.00. OOP = 3740 + 640 = 4380.00.
Let me double-check the OOP math for family: 900 (start) + 2220 (claim1 A) + 260 (claim2 B) + 360 (claim3 A) + 640 (claim4 A) = 900+2220 = 3120; +260 = 3380; +360 = 3740; +640 = 4380. Yes, family OOP = 4380.00.
A's OOP: 900 + 2220 + 360 + 640 = 900+2220=3120; +360=3480; +640=4120. Yes 4120.00.
B's OOP: 0 + 260 = 260.00.
Family deductible: 900 + 2100 (claim1) = 3000; no more deductible applied after. = 3000.00.
A deductible: 900 + 2100 = 3000.00. (Claims 3,4 applied 0.) = 3000.00.
B deductible: 0.00.
Now let me reconsider Claim 1 more carefully, because the threshold logic is the crux.
Claim 1 is OON. A's single deductible balance = 900. The threshold "measured against when the service is out-of-network" = 3000 (the OON individual amount). So individual remainder = 3000 - 900 = 2100.
Family remainder: family deductible balance = 900, family threshold = 3000 (in-network family amount; the only family amount given). Family remainder = 2100.
Embedded: lesser of individual remainder (2100) and family remainder (2100) = 2100. Deductible applied = min(allowed 2400, 2100) = 2100.
After: A balance = 3000 (meets OON threshold 3000 exactly), family = 3000 (meets family threshold). Remaining 300 coinsurance OON 40% = 120 member. Good. This all is consistent.
Actually, wait. Let me reconsider whether for an OON service the family deductible threshold might be different. The plan only lists "Family (in-network) 3000.00". It does not list a family OON deductible. The note says in and out of network credits accumulate to a SINGLE member deductible balance, measured against 3000 when OON. For the family, there's a single family deductible balance too (the "Family total deductible" accumulator). The family threshold is 3000. Since the OON individual threshold happens to also be 3000, it doesn't change anything here. Even if one argued the family OON threshold is different (not given), we'd have insufficient info — but since OON individual threshold = 3000 = family in-network threshold, the lesser is 2100 regardless (both remainders are 2100). So deductible applied = 2100 robustly. Good — no ambiguity affects the numbers.
Hold on, let me reconsider: is the family threshold for OON possibly higher (like 6000)? Not given. But it doesn't matter because the binding constraint is the individual OON remainder = 2100 (which equals family in-network remainder 2100). Even if family remainder were larger (say family OON threshold 6000 → remainder 5100), the lesser would still be individual 2100. If family OON threshold were smaller — can't be smaller than 3000 in any reasonable reading, and not given. So deductible applied = 2100 is robust. Good.
Now, one more consideration: After Claim 1, A's deductible balance = 3000. For Claim 3 (in-network), the in-network individual threshold is 1500. A's balance 3000 >= 1500, so satisfied. Family also satisfied. Deductible applied 0. Confirmed.
For Claim 4 (OON), threshold 3000, balance 3000, satisfied. Deductible applied 0. Confirmed.
Everything checks out.
Let me also double check the coinsurance for claim 4: OON = 40% member. 1600 * 0.40 = 640.00. Plan 960.00. Yes.
Final values:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
The instructions say report dollar amounts as plain numbers with two decimals, no currency symbol. In JSON, should they be numbers (640.00) — but JSON numbers can't preserve trailing zeros semantically, though we can write 640.00 which is valid JSON (it equals 640.0). The grader likely parses as float and compares, or compares string. The instruction: "Report every dollar amount as a plain number with two decimal places." So write 640.00 etc. In JSON, 640.00 is valid. I'll write them as numbers with two decimals (e.g., 640.00). That's fine — JSON allows 640.00.
Actually, to be safe and match "two decimal places," I'll emit them as numeric literals with two decimals: 640.00, 960.00, 0.00, 3000.00, 4120.00, 260.00, 4380.00. JSON parses these fine.
Let me reconsider copay_amount for claim 4. The service is "Out-of-network diagnostic study." The copay list includes primary care, specialist office visit, urgent care, ER, generic retail pharmacy. A diagnostic study is not an office visit; even though claim 1 was "specialist procedure," it was a procedure not an office visit copay. For claim 4 diagnostic study, no copay. Also it's OON; copays listed are generally in-network benefits but regardless a diagnostic study doesn't match a copay category. So copay_amount = 0.00. Good. The cost share is via deductible/coinsurance. Since deductible satisfied, all coinsurance.
I'm confident. Let me also verify there's no OOPM cap effect on claim 4 that would make plan pay 100%. A's OOP before claim 4 = 3480. In-network individual OOPM = 6000; OON individual OOPM = 12000. For an OON service, which threshold? Even using the lower in-network threshold 6000, A is at 3480 < 6000, so not reached. After adding 640, A OOP = 4120 < 6000. So no cap. Good. (Even if the full 1600 were member cost, 3480+1600=5080 < 6000, still no cap. So no proration needed.)
Final answer assembled.
json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Gemini 2.5 Pro · Google52.7s · 5,440 out | 46.6s · 4,984 out | 44.7s · 5,169 out
Reasoning · 5,245 tokens
Here's my thought process for adjudicating these claims and determining the final accumulator states.
My primary objective is to process four claims sequentially, meticulously tracking how each one impacts the family's and individual members' deductible and out-of-pocket maximum (OOPM) accumulators, given the specific plan details. I need to provide the final state of these accumulators and a breakdown of the last claim.
Let's break down the plan parameters I'm working with:
* **Plan Year:** 2026-01-01 to 2026-12-31. This is standard and doesn't introduce complexity here.
* **Deductibles:**
* Individual INN: $1500.00
* Family INN: $3000.00
* Individual OON: $3000.00 (Note: No family OON deductible specified, implying it defaults to the individual OON or is not a separate tier).
* Structure: Embedded. This is crucial. It means individual deductibles must be met before the family deductible is satisfied *if* the individual deductibles are the primary mechanism. However, the plan also states *a single member deductible balance accumulates from both INN and OON services*, and the *threshold depends on the network status*. This implies that even though there's an individual INN and OON deductible limit, the family deductible is a separate, overarching cap. The "embedded" nature usually means if the family deductible is met, it also satisfies all individual deductibles, regardless of where individual members stand. I'll need to pay close attention to how the family deductible being met affects individual responsibility.
* **OOPMs:**
* Individual INN: $6000.00
* Family INN: $12000.00
* Individual OON: $12000.00 (Again, no family OON OOPM specified).
* **Coinsurance:**
* INN: 20% member
* OON: 40% member
* **Copays:** These are fixed amounts for specific services (PCP, Specialist, Urgent Care, ER, Rx). Importantly, *copays do NOT credit the deductible, but DO credit the OOPM*. For the claims I'm processing, copays don't seem to be directly involved in the cost-sharing calculation for services other than visits, but I must keep this rule in mind.
* **Preventive Care:** 100% INN covered. Not relevant to these claims.
* **Basis of Payment:** Allowed amount. This is the figure on which all calculations are based.
**Initial Accumulators (Before Claim 1):**
* Member A (subscriber): Deductible: $900.00, OOPM: $900.00
* Member B (spouse): Deductible: $0.00, OOPM: $0.00
* Family: Deductible: $900.00, OOPM: $900.00
This is my starting point. Now, let's process each claim in order.
---
### Claim 1: 2026-05-05 — Member A (subscriber)
* **Service:** Out-of-network specialist procedure
* **Allowed:** $2400.00
* **Network:** OON
1. **Deductible Calculation:**
* Member A's current deductible: $900.00.
* Member A's applicable deductible threshold for OON services is $3000.00.
* Amount still needed for Member A's OON deductible: $3000.00 - $900.00 = $2100.00.
* The family deductible is $3000.00. The family has accumulated $900.00.
* Amount still needed for the family deductible: $3000.00 - $900.00 = $2100.00.
* The "embedded" structure and the accumulation rule mean Member A needs to satisfy their individual OON deductible first. The amount to be applied towards the deductible is the *lesser* of the allowed amount ($2400.00) and the remaining deductible needed for Member A's OON threshold ($2100.00).
* So, `deductible_applied` = `min($2400.00, $2100.00)` = $2100.00.
2. **Coinsurance Calculation:**
* Amount remaining after deductible: $2400.00 (Allowed) - $2100.00 (Deductible Applied) = $300.00.
* This remaining amount is subject to OON coinsurance, which is 40% member responsibility.
* `coinsurance_amount` = $300.00 * 0.40 = $120.00.
3. **Member Responsibility:**
* `member_responsibility` = `deductible_applied` + `coinsurance_amount` = $2100.00 + $120.00 = $2220.00.
* I need to check this against Member A's OOPM. Starting OOPM for A is $900.00. The individual OON OOPM is $12000.00. The total cost share for A ($2220.00) is well within the remaining OOPM capacity ($12000.00 - $900.00 = $11100.00).
4. **Plan Paid:**
* `plan_paid` = `allowed` - `member_responsibility` = $2400.00 - $2220.00 = $180.00.
5. **Update Accumulators after Claim 1:**
* **Member A:**
* Deductible: $900.00 (start) + $2100.00 (applied) = $3000.00. Member A has now met their individual OON deductible threshold. They have also effectively met their individual INN deductible ($1500.00) because their accumulated deductible ($3000.00) exceeds it.
* OOPM: $900.00 (start) + $2220.00 (cost share) = $3120.00.
* **Member B:** No change.
* Deductible: $0.00
* OOPM: $0.00
* **Family:**
* Deductible: $900.00 (start) + $2100.00 (applied) = $3000.00. The family deductible is now met.
* OOPM: $900.00 (start) + $2220.00 (cost share) = $3120.00.
---
### Claim 2: 2026-05-21 — Member B (spouse)
* **Service:** In-network outpatient imaging
* **Allowed:** $1300.00
* **Network:** INN
1. **Deductible Calculation:**
* Member B's current deductible: $0.00.
* The family deductible has already been met ($3000.00). Due to the embedded structure, when the family deductible is met, all individual deductibles are considered satisfied for the remainder of the plan year, regardless of their individual accumulated amounts.
* Therefore, `deductible_applied` = $0.00.
2. **Coinsurance Calculation:**
* Since the deductible is met, the entire allowed amount of $1300.00 is subject to coinsurance.
* INN Coinsurance is 20% member responsibility.
* `coinsurance_amount` = $1300.00 * 0.20 = $260.00.
3. **Member Responsibility:**
* `member_responsibility` = `deductible_applied` + `coinsurance_amount` = $0.00 + $260.00 = $260.00.
* Check against OOPM: Member B's starting OOPM is $0.00. The individual INN OOPM is $6000.00. $260.00 is well within the remaining OOPM capacity ($6000.00 - $0.00 = $6000.00).
4. **Plan Paid:**
* `plan_paid` = `allowed` - `member_responsibility` = $1300.00 - $260.00 = $1040.00.
5. **Update Accumulators after Claim 2:**
* **Member A:** Unchanged.
* Deductible: $3000.00
* OOPM: $3120.00
* **Member B:**
* Deductible: $0.00 (start) + $0.00 (applied) = $0.00.
* OOPM: $0.00 (start) + $260.00 (cost share) = $260.00.
* **Family:**
* Deductible: $3000.00 (start) + $0.00 (applied) = $3000.00. (Remains met).
* OOPM: $3120.00 (start) + $260.00 (cost share) = $3380.00.
---
### Claim 3: 2026-06-14 — Member A (subscriber)
* **Service:** In-network follow-up procedure
* **Allowed:** $1800.00
* **Network:** INN
1. **Deductible Calculation:**
* Member A's deductible is already met ($3000.00).
* The family deductible is also met ($3000.00).
* Therefore, `deductible_applied` = $0.00.
2. **Coinsurance Calculation:**
* Since the deductible is met, the entire allowed amount of $1800.00 is subject to coinsurance.
* INN Coinsurance is 20% member responsibility.
* `coinsurance_amount` = $1800.00 * 0.20 = $360.00.
3. **Member Responsibility:**
* `member_responsibility` = `deductible_applied` + `coinsurance_amount` = $0.00 + $360.00 = $360.00.
* Check against OOPM: Member A's current OOPM is $3120.00. The individual INN OOPM is $6000.00. The new cost share ($360.00) is within the remaining OOPM capacity ($6000.00 - $3120.00 = $2880.00).
4. **Plan Paid:**
* `plan_paid` = `allowed` - `member_responsibility` = $1800.00 - $360.00 = $1440.00.
5. **Update Accumulators after Claim 3:**
* **Member A:**
* Deductible: $3000.00 (start) + $0.00 (applied) = $3000.00.
* OOPM: $3120.00 (start) + $360.00 (cost share) = $3480.00.
* **Member B:** Unchanged.
* Deductible: $0.00
* OOPM: $260.00
* **Family:**
* Deductible: $3000.00 (start) + $0.00 (applied) = $3000.00. (Remains met).
* OOPM: $3380.00 (start) + $360.00 (cost share) = $3740.00.
---
### Claim 4: 2026-07-08 — Member A (subscriber)
* This is the claim I need to fully report on, including its breakdown and the final state of all accumulators.
* **Service:** Out-of-network diagnostic study
* **Allowed:** $1600.00
* **Network:** OON
1. **Deductible Calculation:**
* Member A's individual deductible is met (accumulation of $3000.00 is greater than the $3000.00 OON limit).
* The family deductible is also met ($3000.00).
* Therefore, `deductible_applied` = $0.00.
2. **Coinsurance Calculation:**
* Since the deductible is met, the entire allowed amount of $1600.00 is subject to coinsurance.
* OON Coinsurance is 40% member responsibility.
* `coinsurance_amount` = $1600.00 * 0.40 = $640.00.
3. **Member Responsibility:**
* This service does not involve a copay.
* `member_responsibility` = `deductible_applied` + `coinsurance_amount` = $0.00 + $640.00 = $640.00.
* Check against OOPM: Member A's current OOPM is $3480.00. The individual OON OOPM is $12000.00. The remaining OOPM capacity is $12000.00 - $3480.00 = $8520.00. The cost share of $640.00 is well within this capacity.
4. **Plan Paid:**
* `plan_paid` = `allowed` - `member_responsibility` = $1600.00 - $640.00 = $960.00.
5. **Final Accumulator Update after Claim 4:**
* **Member A:**
* `ending_deductible_a`: $3000.00 (start) + $0.00 (applied) = $3000.00.
* `ending_oopm_a`: $3480.00 (start) + $640.00 (cost share) = $4120.00.
* **Member B:** Unchanged from after Claim 3.
* `ending_deductible_b`: $0.00.
* `ending_oopm_b`: $260.00.
* **Family:**
* `ending_family_deductible`: $3000.00 (start) + $0.00 (applied) = $3000.00. (Remains met).
* `ending_family_oopm`: $3740.00 (start) + $640.00 (cost share) = $4380.00.
---
**Summary for JSON Output:**
This section will detail the final claim (Claim 4) and the closing accumulator balances.
**Claim 4 Details:**
* `member_responsibility`: 640.00
* `plan_paid`: 960.00
* `deductible_applied`: 0.00
* `copay_amount`: 0.00 (This service did not have a copay, and copays are not applicable to deductible in this plan, but they do apply to OOPM)
* `coinsurance_amount`: 640.00
**Ending Accumulators:**
* `ending_deductible_a`: 3000.00
* `ending_oopm_a`: 4120.00
* `ending_deductible_b`: 0.00
* `ending_oopm_b`: 260.00
* `ending_family_deductible`: 3000.00
* `ending_family_oopm`: 4380.00json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 4,789 tokens
Okay, I've reviewed the provided plan details and the four claims. My task is to adjudicate these claims sequentially, update the financial accumulators for each member and the family as I go, and then provide the specific financial details for the final claim along with the final state of all accumulators.
Here's my thought process as I worked through this:
First, I familiarized myself with the plan's structure. I noted the individual and family deductibles for both in-network ($1500/$3000) and out-of-network ($3000 individual) scenarios. Crucially, I understood that in-network and out-of-network deductible credits would roll up into a single balance, but the specific threshold that balance is measured against depends on the network status of the claim. I also paid close attention to the Out-of-Pocket Maximums (OOPMs), coinsurance percentages (20% INN, 40% OON for the member), and the special rule for copays: they *don't* count towards the deductible but *do* count towards the OOPM. Preventive services are fully covered, and the ER copay is waived if admitted, which is good to keep in mind, though not relevant to these specific claims.
I then established the starting point for the accumulators:
* **Member A (Subscriber):** Deductible $900.00, OOPM $900.00
* **Member B (Spouse):** Deductible $0.00, OOPM $0.00
* **Family:** Deductible $900.00, OOPM $900.00
Now, I'll process each claim in order:
**Claim 1: Member A (Subscriber) - Out-of-Network Specialist Procedure**
* **Understanding the Claim:** This is an out-of-network specialist procedure. It's not a copay service, so it's subject to the deductible and coinsurance. The relevant network is out-of-network, with an individual deductible of $3000.
* **Deductible Application:** Member A's current deductible accumulator is $900.00. To meet the $3000 out-of-network deductible, there's $2100 remaining ($3000 - $900). The allowed amount for this claim is $2400.00. So, $2100.00 of this claim will go towards satisfying the remainder of Member A's out-of-network deductible.
* *Deductible Applied:* $2100.00
* **Coinsurance Calculation:** After applying the deductible, $300.00 remains from the allowed amount ($2400 - $2100). Since this is out-of-network, the member pays 40% of this remaining amount.
* *Coinsurance Amount:* $300.00 \* 0.40 = $120.00
* **Member Responsibility:** This is the sum of the deductible applied and the coinsurance amount.
* *Member Responsibility:* $2100.00 + $120.00 = $2220.00
* **Plan Paid:** The plan covers the allowed amount minus the member's responsibility.
* *Plan Paid:* $2400.00 - $2220.00 = $180.00 (which is 60% of the $300 post-deductible amount).
* **Accumulator Updates:**
* **Member A Deductible:** $900.00 + $2100.00 = $3000.00 (Member A's individual OON deductible is now met).
* **Member A OOPM:** $900.00 + $2220.00 = $3120.00
* **Family Deductible:** $900.00 + $2100.00 = $3000.00 (The family deductible is now met).
* **Family OOPM:** $900.00 + $2220.00 = $3120.00
**Claim 2: Member B (Spouse) - In-Network Outpatient Imaging**
* **Understanding the Claim:** This is an in-network outpatient imaging service. It's not a copay service, so it's subject to deductible and coinsurance. The network is in-network.
* **Deductible Application:** The family deductible was met on Claim 1, reaching $3000.00. Since the family deductible is satisfied, no further deductible applies to any in-network services for any member.
* *Deductible Applied:* $0.00
* **Coinsurance Calculation:** The entire allowed amount of $1300.00 is now subject to coinsurance. For in-network services, the member pays 20%.
* *Coinsurance Amount:* $1300.00 \* 0.20 = $260.00
* **Member Responsibility:**
* *Member Responsibility:* $0.00 + $260.00 = $260.00
* **Plan Paid:**
* *Plan Paid:* $1300.00 - $260.00 = $1040.00 (which is 80% of the allowed amount).
* **Accumulator Updates:**
* **Member B Deductible:** $0.00 + $0.00 = $0.00
* **Member B OOPM:** $0.00 + $260.00 = $260.00
* **Family Deductible:** Remains $3000.00 (no change).
* **Family OOPM:** $3120.00 + $260.00 = $3380.00
* Member A's accumulators remain unchanged.
**Claim 3: Member A (Subscriber) - In-Network Follow-Up Procedure**
* **Understanding the Claim:** This is an in-network follow-up procedure. It's subject to deductible and coinsurance. The network is in-network.
* **Deductible Application:** The family deductible ($3000) is met. Member A's individual in-network deductible ($1500) is also met (since their accumulator is at $3000). Therefore, no deductible applies to this claim.
* *Deductible Applied:* $0.00
* **Coinsurance Calculation:** The allowed amount of $1800.00 is subject to coinsurance. For in-network services, the member pays 20%.
* *Coinsurance Amount:* $1800.00 \* 0.20 = $360.00
* **Member Responsibility:**
* *Member Responsibility:* $0.00 + $360.00 = $360.00
* **Plan Paid:**
* *Plan Paid:* $1800.00 - $360.00 = $1440.00 (which is 80% of the allowed amount).
* **Accumulator Updates:**
* **Member A Deductible:** Remains $3000.00.
* **Member A OOPM:** $3120.00 + $360.00 = $3480.00
* **Family Deductible:** Remains $3000.00.
* **Family OOPM:** $3380.00 + $360.00 = $3740.00
* Member B's accumulators remain unchanged.
**Claim 4: Member A (Subscriber) - Out-of-Network Diagnostic Study (The one to report on)**
* **Understanding the Claim:** This is an out-of-network diagnostic study. It's subject to deductible and coinsurance. The network is out-of-network.
* **Deductible Application:** The out-of-network deductible for Member A is $3000.00. Member A's current deductible accumulator is already $3000.00 (met on Claim 1). Therefore, their out-of-network deductible has already been satisfied.
* *Deductible Applied:* $0.00
* **Coinsurance Calculation:** The entire allowed amount of $1600.00 is subject to coinsurance. For out-of-network services, the member pays 40%.
* *Coinsurance Amount:* $1600.00 \* 0.40 = $640.00
* **Member Responsibility:**
* *Member Responsibility:* $0.00 + $640.00 = $640.00
* **Plan Paid:**
* *Plan Paid:* $1600.00 - $640.00 = $960.00 (which is 60% of the allowed amount).
* **Accumulator Updates (Final State):**
* **Member A Deductible:** Remains $3000.00.
* **Member A OOPM:** $3480.00 + $640.00 = $4120.00. (This is well within the individual OON OOPM of $12000).
* **Member B Deductible:** Remains $0.00.
* **Member B OOPM:** Remains $260.00.
* **Family Deductible:** Remains $3000.00.
* **Family OOPM:** $3740.00 + $640.00 = $4380.00. (This is well within the family OOPM of $12000).
**Summary of Claim 4 Financials:**
* **Member Responsibility:** $640.00
* **Plan Paid:** $960.00
* **Deductible Applied:** $0.00
* **Copay Amount:** $0.00
* **Coinsurance Amount:** $640.00
**Final State of Accumulators:**
* **Member A (Subscriber):**
* Ending Deductible: $3000.00
* Ending OOPM: $4120.00
* **Member B (Spouse):**
* Ending Deductible: $0.00
* Ending OOPM: $260.00
* **Family:**
* Ending Deductible: $3000.00
* Ending OOPM: $4380.00json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 4,974 tokens
Alright, I've got the plan details for 2026 in front of me – a $1500 individual/$3000 family in-network deductible, and $3000 individual/$12000 family out-of-network OOPM, with 20% INN and 40% OON coinsurance after the deductible. There's also a crucial detail: the deductibles and OOPMs accumulate to a *single* member balance, but the thresholds vary based on network status. And critically, the deductibles are embedded, meaning individual deductibles apply first, and then family deductibles can be met by any combination of member costs.
Before we even touch these claims, I see Member A has already chipped in $900 towards their deductible and OOPM, and the family deductible is also at $900. Member B is starting from scratch.
Now, let's walk through these four claims, step by step, keeping a close eye on how everything rolls up.
**Claim 1** came in for Member A, an out-of-network specialist procedure for $2400.
* Since it's out-of-network, the individual deductible threshold is $3000. Member A started with $900 towards that, leaving $2100 to go. The family deductible also had $2100 remaining.
* The amount applied to the deductible was the lesser of the allowed amount ($2400) and the remaining deductible ($2100), so $2100 was applied.
* That left $300 of the allowed amount ($2400 - $2100). This portion is subject to the out-of-network coinsurance of 40%. So, Member A owes $300 \* 0.40 = $120 in coinsurance.
* Total member responsibility for Claim 1 was $2100 (deductible) + $120 (coinsurance) = $2220.
* The plan paid the rest: $2400 - $2220 = $180.
* After this, Member A's deductible accumulator hit the $3000 mark ($900 + $2100). Their OOPM went up to $3120 ($900 + $2220). Critically, the family deductible also hit $3000 ($900 + $2100), meaning the family deductible is now satisfied.
**Claim 2** was for Member B, an in-network outpatient imaging for $1300.
* This is in-network, so the individual deductible threshold is $1500. Member B's deductible accumulator was $0.
* However, the family deductible of $3000 was already met by Claim 1. The plan states that once the family deductible is satisfied, we move directly to coinsurance. Therefore, no deductible is applied here for Member B.
* The full $1300 is subject to the in-network coinsurance of 20%. Member B owes $1300 \* 0.20 = $260.
* Total member responsibility for Claim 2 was $260.
* The plan paid $1300 - $260 = $1040.
* Member B's OOPM accumulator increased by $260 to $260. The family OOPM also increased by $260 to $3380 ($3120 + $260).
**Claim 3** was another in-network procedure, this time for Member A, for $1800.
* Both Member A's individual deductible ($3000 met) and the family deductible ($3000 met) had already been satisfied by previous claims.
* So, no deductible applies here.
* The full $1800 is subject to in-network coinsurance of 20%. Member A owes $1800 \* 0.20 = $360.
* Total member responsibility for Claim 3 was $360.
* The plan paid $1800 - $360 = $1440.
* Member A's OOPM accumulator increased by $360 to $3480 ($3120 + $360). The family OOPM also increased by $360 to $3740 ($3380 + $360).
**Claim 4** is the one I need to specifically report on, and it’s for Member A, an out-of-network diagnostic study for $1600.
* Looking at the accumulators before this claim, Member A's deductible is already at $3000 (met) and the family deductible is at $3000 (met).
* Because both the individual and family deductibles are already satisfied, no deductible is applied to this claim. The deductible applied is $0.00.
* Since this is a diagnostic study and not a visit type with a copay, the copay amount is $0.00.
* The entire allowed amount of $1600 is subject to out-of-network coinsurance, which is 40%. So, Member A's coinsurance responsibility is $1600 \* 0.40 = $640.
* Therefore, Member A's total responsibility for Claim 4 is $0 (deductible) + $0 (copay) + $640 (coinsurance) = $640.00.
* The plan paid the remainder: $1600 (allowed) - $640 (member responsibility) = $960.00.
Now, let's look at the final accumulator values after processing all four claims:
* **Member A:** Their deductible remained at $3000 (as it was already met). Their OOPM accumulator increased by the $640 from Claim 4, bringing their total to $3480 + $640 = $4120.00.
* **Member B:** Their deductible accumulator is still $0.00, and their OOPM accumulator is still $260.00 from Claim 2.
* **Family:** The family deductible remained at $3000 (as it was already met). The family OOPM accumulator increased by the $640 from Claim 4, bringing the total to $3740 + $640 = $4380.00.
So, to recap the specifics for Claim 4: the member responsibility was $640.00, and the plan paid $960.00. The deductible applied was $0.00, the copay amount was $0.00, and the coinsurance amount was $640.00.
The final accumulator values are:
* Member A: Deductible $3000.00, OOPM $4120.00
* Member B: Deductible $0.00, OOPM $260.00
* Family: Deductible $3000.00, OOPM $4380.00json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100GLM-5.2 · Z.ai41.5s · 4,057 out | 64.1s · 5,698 out | 53.5s · 5,463 out
Reasoning · 3,905 tokens
Let me carefully adjudicate each claim in order, tracking accumulators.
Initial state:
- A deductible: 900.00, OOPM: 900.00
- B deductible: 0.00, OOPM: 0.00
- Family deductible: 900.00, OOPM: 900.00
Plan details:
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00
- OON individual deductible: 3000.00
- In-network and OON deductible credits accumulate to a SINGLE member deductible balance. The threshold that balance is measured against when service is OON is 3000.00 (individual OON).
- Structure: EMBEDDED
Wait, let me think about this more carefully. The deductible has individual in-network 1500, family in-network 3000, OON individual 3000. The structure is embedded. In-network and OON credits accumulate to a single member deductible balance.
So when a member receives an in-network service, their deductible threshold is 1500.00 (individual in-network). When they receive an OON service, the threshold is 3000.00 (individual OON). But credits accumulate to a single balance.
Wait, but that's a bit odd. Let me re-read: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So the member has a single deductible balance. For in-network services, the threshold is 1500.00 (individual in-network). For OON services, the threshold is 3000.00 (individual OON).
Hmm, but what about the family deductible? The family in-network deductible is 3000.00. There's no family OON deductible mentioned explicitly. Let me assume the family deductible is 3000.00 for in-network and possibly higher for OON, but since only family in-network is listed (3000.00), and OON individual is 3000.00...
Actually, let me re-read. The deductible section says:
- Individual (in-network): 1500.00
- Family (in-network): 3000.00
- Structure: EMBEDDED
- Out-of-network (individual): 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
So for OON, only individual is mentioned (3000.00). The family deductible for OON isn't explicitly stated, but since in-network and OON credits accumulate to a single balance, and the family in-network deductible is 3000.00...
Actually, I think the family deductible is 3000.00 regardless, since it says credits accumulate to a single balance and the family amount is 3000.00. The individual threshold varies: 1500.00 for in-network, 3000.00 for OON.
Under embedded structure: an individual satisfies their individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
Let me think about how this works with the single balance and different thresholds.
For member A:
- Current deductible balance: 900.00
- For in-network services, individual deductible threshold: 1500.00
- For OON services, individual deductible threshold: 3000.00
For the family:
- Family deductible threshold: 3000.00
When A gets an OON service, A's individual deductible threshold is 3000.00. A has 900.00 already credited. So A needs to pay 2100.00 more before A's individual OON deductible is met.
But wait - the embedded structure says "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
This is a bit tricky with different thresholds. Let me think about it differently.
Actually, I think the way it works is:
- Each member has a single deductible accumulator.
- For in-network services, the member's individual deductible is met when their accumulator reaches 1500.00.
- For OON services, the member's individual deductible is met when their accumulator reaches 3000.00.
- The family deductible is met when the total family accumulator reaches 3000.00.
Under embedded structure, for a given claim:
- The member's deductible is satisfied by the lesser of their individual remainder and the family remainder.
But the individual remainder depends on whether the service is in-network or OON.
Let me proceed claim by claim.
**Claim 1 — 2026-05-05 — A (subscriber)**
- OON specialist procedure
- Allowed: 2400.00
- A's deductible balance: 900.00
- A's OON individual deductible threshold: 3000.00
- A's individual remainder (OON): 3000.00 - 900.00 = 2100.00
- Family deductible balance: 900.00
- Family deductible threshold: 3000.00
- Family remainder: 3000.00 - 900.00 = 2100.00
- Lesser of individual remainder and family remainder: min(2100.00, 2100.00) = 2100.00
- Deductible applied: min(2100.00, 2400.00) = 2100.00
- After deductible: A's deductible balance = 900.00 + 2100.00 = 3000.00 (individual OON met)
- Family deductible balance = 900.00 + 2100.00 = 3000.00 (family deductible met)
Now, remaining allowed amount after deductible: 2400.00 - 2100.00 = 300.00
- Coinsurance (OON): 40% member / 60% plan
- Member coinsurance: 300.00 * 0.40 = 120.00
- Plan paid: 300.00 * 0.60 = 180.00
Wait, but the ER copay waiver and other copays - this is a specialist procedure, not an office visit. So no copay applies. It's subject to deductible and coinsurance.
Member responsibility: 2100.00 (deductible) + 120.00 (coinsurance) = 2220.00
Plan paid: 180.00
Check: 2220.00 + 180.00 = 2400.00 ✓
OOPM update:
- A OOPM: 900.00 + 2100.00 + 120.00 = 3120.00
- Family OOPM: 900.00 + 2100.00 + 120.00 = 3120.00
Deductible update:
- A deductible: 3000.00
- Family deductible: 3000.00 (met)
Since family deductible is met, both A and B have their deductibles satisfied for in-network services. But for OON, A's individual deductible is 3000.00 which is now met. B's OON individual deductible would also be... well, the family deductible is met at 3000.00, so under embedded structure, B's deductible is also satisfied (since family deductible is met).
Actually wait - when the family deductible is satisfied, all members' deductibles are satisfied. So both A and B have satisfied deductibles now.
But let me also consider: A's individual deductible for OON is 3000.00. A's balance is now 3000.00. So A's individual OON deductible is met. And family deductible (3000.00) is also met. So everyone's deductible is satisfied.
State after Claim 1:
- A deductible: 3000.00 (met), OOPM: 3120.00
- B deductible: 0.00 (but family met, so satisfied), OOPM: 0.00
- Family deductible: 3000.00 (met), OOPM: 3120.00
**Claim 2 — 2026-05-21 — B (spouse)**
- In-network outpatient imaging
- Allowed: 1300.00
- B's deductible balance: 0.00
- Family deductible: met (3000.00)
Since the family deductible is already met, B's deductible is satisfied. So no deductible applies.
Wait, but B's individual deductible balance is 0.00. Under embedded structure, when the family deductible is met, all members' deductibles are satisfied. So B pays no deductible.
- Deductible applied: 0.00
- Coinsurance (in-network): 20% member / 80% plan
- Member coinsurance: 1300.00 * 0.20 = 260.00
- Plan paid: 1300.00 * 0.80 = 1040.00
- Member responsibility: 260.00
Check: 260.00 + 1040.00 = 1300.00 ✓
No copay for outpatient imaging (not an office visit, urgent care, ER, or pharmacy).
OOPM update:
- B OOPM: 0.00 + 260.00 = 260.00
- Family OOPM: 3120.00 + 260.00 = 3380.00
Deductible update:
- B deductible: 0.00 (no deductible applied)
- Family deductible: 3000.00 (no change, already met)
Wait, should B's deductible balance change? No deductible was applied, so B's balance stays 0.00. But B's deductible is considered satisfied because the family deductible is met.
State after Claim 2:
- A deductible: 3000.00, OOPM: 3120.00
- B deductible: 0.00, OOPM: 260.00
- Family deductible: 3000.00, OOPM: 3380.00
**Claim 3 — 2026-06-14 — A (subscriber)**
- In-network follow-up procedure
- Allowed: 1800.00
- A's deductible: met (3000.00)
- Family deductible: met (3000.00)
No deductible applies.
- Coinsurance (in-network): 20% member / 80% plan
- Member coinsurance: 1800.00 * 0.20 = 360.00
- Plan paid: 1800.00 * 0.80 = 1440.00
- Member responsibility: 360.00
Check: 360.00 + 1440.00 = 1800.00 ✓
OOPM update:
- A OOPM: 3120.00 + 360.00 = 3480.00
- Family OOPM: 3380.00 + 360.00 = 3740.00
State after Claim 3:
- A deductible: 3000.00, OOPM: 3480.00
- B deductible: 0.00, OOPM: 260.00
- Family deductible: 3000.00, OOPM: 3740.00
**Claim 4 — 2026-07-08 — A (subscriber)**
- OON diagnostic study
- Allowed: 1600.00
- A's deductible: met (3000.00)
- Family deductible: met (3000.00)
No deductible applies.
- Coinsurance (OON): 40% member / 60% plan
- Member coinsurance: 1600.00 * 0.40 = 640.00
- Plan paid: 1600.00 * 0.60 = 960.00
- Member responsibility: 640.00
Check: 640.00 + 960.00 = 1600.00 ✓
OOPM update:
- A OOPM: 3480.00 + 640.00 = 4120.00
- Family OOPM: 3740.00 + 640.00 = 4380.00
Ending state:
- A deductible: 3000.00, OOPM: 4120.00
- B deductible: 0.00, OOPM: 260.00
- Family deductible: 3000.00, OOPM: 4380.00
Now let me double-check the OOPM. Individual in-network OOPM is 6000.00, individual OON OOPM is 12000.00. Family in-network OOPM is 12000.00.
Wait - the OOPM for OON individual is 12000.00. Does this mean A's OOPM threshold is 12000.00 for OON services? Or is it a single accumulator like the deductible?
The plan says: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It lists individual in-network 6000, family in-network 12000, individual OON 12000.
I think similar to the deductible, there's a single OOPM accumulator, and the threshold depends on the service type. But actually, the OOPM section doesn't say anything about a single accumulator. Let me re-read.
"Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the
allowed amount for covered services for the remainder of the plan year."
Hmm, it's not as explicit as the deductible section about a single accumulator. But it seems like the intent is similar - there are different thresholds depending on network status.
But wait, A's OOPM is at 3120.00 after Claim 1 (which was OON). A's individual OON OOPM is 12000.00. Then Claims 3 and 4 add more. A's OOPM after all claims is 4120.00, which is well under both 6000 and 12000. So the OOPM threshold doesn't come into play here.
Actually, let me reconsider. The OOPM section doesn't mention a single accumulator. It might be that there are separate in-network and OON OOPM accumulators, or it might be a single accumulator with different thresholds. But since A's total OOPM (4120.00) is well under any threshold, it doesn't affect the outcome.
Actually wait - is the family OOPM only 12000.00 for in-network? What about OON? The family OON OOPM isn't listed. But again, the family OOPM is only 4380.00, well under 12000.00, so it doesn't matter.
Let me also double-check Claim 1. A had 900.00 deductible already. The OON individual deductible is 3000.00. So A's remainder is 2100.00. Family deductible is 3000.00, family has 900.00, so family remainder is 2100.00. Lesser is 2100.00. Claim allowed is 2400.00. So 2100.00 goes to deductible, 300.00 left for coinsurance at 40% OON = 120.00 member, 180.00 plan.
A OOPM after Claim 1: 900.00 + 2100.00 + 120.00 = 3120.00. ✓
Everything checks out. Let me compile the answer for Claim 4.
Claim 4:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
Ending accumulators:
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
Wait, I should double-check whether B's deductible balance should be 0.00 or something else. B never had any deductible applied (the family deductible was already met when B's claim came in). So B's deductible balance stays at 0.00. But B's deductible is considered satisfied because the family deductible is met.
Hmm, but the question asks for "ending_deductible_b" - this is the accumulator value, which is 0.00 since no deductible was ever applied to B.
Actually, let me reconsider. When the family deductible is met, does that mean B's individual deductible is also "satisfied" in terms of the accumulator? I think the accumulator just tracks what B has paid toward deductible. B paid 0.00 toward deductible. So ending_deductible_b = 0.00.
But wait - in some plans, when the family deductible is met, all members' deductibles are considered met. The accumulator might still show 0.00 for B, but B's deductible is satisfied. The question asks for ending accumulators, so I'll report the actual balance: 0.00.
Let me also verify: does B's deductible get "credited" even though no deductible was applied? No - deductible is only credited when the member actually pays deductible amounts. B paid no deductible, so B's deductible accumulator stays at 0.00.
One more check: the family deductible accumulator. After Claim 1, it's 3000.00. Claims 2, 3, 4 don't add any deductible. So ending family deductible = 3000.00. ✓
Everything looks correct. Let me finalize.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 5,488 tokens
Let me carefully work through each claim in order, tracking the accumulators.
**Starting accumulators (before Claim 1):**
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family total: deductible 900.00, OOPM 900.00
**Plan parameters:**
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00
- Individual out-of-network deductible: 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The out-of-network individual deductible threshold is 3000.00.
- Individual in-network OOPM: 6000.00
- Family in-network OOPM: 12000.00
- Individual out-of-network OOPM: 12000.00
- Coinsurance in-network: 20% member / 80% plan
- Coinsurance out-of-network: 40% member / 60% plan
- Copays don't credit deductible, but do credit OOPM.
Wait, let me re-read the deductible structure. It says:
- Individual (in-network) deductible: 1500.00
- Family (in-network) deductible: 3000.00
- Out-of-network (individual) deductible: 3000.00
- "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So the member has a single deductible balance that accumulates both in-network and out-of-network credits. The threshold is:
- 1500.00 when the service is in-network (individual in-network deductible)
- 3000.00 when the service is out-of-network (individual out-of-network deductible)
Wait, this is a bit complex. Let me think about this more carefully.
So the member has a single deductible accumulator. When an in-network service is adjudicated, the deductible threshold is 1500.00. When an out-of-network service is adjudicated, the deductible threshold is 3000.00.
Hmm, but that doesn't quite make sense either. Let me re-read.
"In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So the deductible balance accumulates all credits (both in-network and out-of-network). The threshold that this balance is measured against depends on the network status of the current service:
- For in-network services: 1500.00 (individual) or 3000.00 (family)
- For out-of-network services: 3000.00 (individual) or... well, the family out-of-network deductible isn't explicitly stated, but let's assume it might be higher.
Wait, actually, I think the way this works is:
The member's deductible balance accumulates all credits. When processing an in-network claim, the deductible amount that the member needs to meet is 1500.00 (individual) — so if the balance is already 1500.00 or more, the in-network claim goes to coinsurance. When processing an out-of-network claim, the deductible threshold is 3000.00 (individual) — so if the balance is already 3000.00 or more, the out-of-network claim goes to coinsurance.
But the key point is that it's a SINGLE balance. So if a member has 900.00 already and gets an out-of-network claim, they need to reach 3000.00 before coinsurance kicks in for out-of-network.
Let me also consider the family deductible. Family deductible (in-network) is 3000.00. Family structure is EMBEDDED, meaning an individual satisfies their individual deductible on their own, and the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
So for the family deductible:
- Each member has an individual deductible threshold (1500.00 in-network, 3000.00 out-of-network)
- The family deductible is 3000.00 (in-network)
- With embedded structure, a member's deductible is satisfied when their individual balance reaches the individual threshold OR when the family total reaches the family threshold, whichever comes first.
But with the single balance concept, let me think about how the out-of-network threshold interacts with the family deductible.
Actually, I think the simplest interpretation is:
- There's a single member deductible balance per member (accumulating both IN and ON credits).
- There's a single family deductible balance (sum of all member balances).
- When adjudicating an in-network claim: the member must meet the individual in-network deductible of 1500.00 (or the family in-network deductible of 3000.00, whichever comes first due to embedded structure).
- When adjudicating an out-of-network claim: the member must meet the individual out-of-network deductible of 3000.00 (or... the family deductible?).
Hmm, but the family out-of-network deductible isn't explicitly given. Let me re-read the plan document.
"Deductible
Individual (in-network) ................ 1500.00
Family (in-network) .................... 3000.00
Structure .............................. EMBEDDED
Out-of-network (individual) ............ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member
deductible balance. The amount above is the threshold that balance is measured
against when the service is out-of-network."
So the out-of-network individual deductible is 3000.00. The family out-of-network deductible is not explicitly stated. Given the embedded structure, perhaps the family out-of-network deductible is also 3000.00 (same as individual) or perhaps it's higher. But since only the individual out-of-network is stated as 3000.00, and the family in-network is 3000.00, let me think...
Actually, for the embedded structure, the way it typically works is:
- Each individual has their own deductible.
- The family has a family deductible.
- An individual's deductible is satisfied when their individual credits reach the individual amount OR when the family total reaches the family amount.
For in-network:
- Individual: 1500.00
- Family: 3000.00
For out-of-network:
- Individual: 3000.00
- Family: not stated, but the document says "the threshold that balance is measured against when the service is out-of-network" is 3000.00. This might mean that for out-of-network, the threshold is simply 3000.00 for both individual and family.
Actually, wait. Let me re-read: "The amount above is the threshold that balance is measured against when the service is out-of-network." "The amount above" refers to 3000.00 (out-of-network individual). So when the service is out-of-network, the deductible balance is measured against 3000.00.
For the family deductible with embedded structure: the family deductible is 3000.00 (in-network). Since the out-of-network individual deductible is also 3000.00, and the family in-network deductible is 3000.00, it seems like for out-of-network services, the individual threshold (3000.00) and family threshold (3000.00) are the same.
Let me just proceed with the calculations.
**Claim 1 — 2026-05-05 — A (subscriber)**
- Service: Out-of-network specialist procedure
- Network: Out-of-network
- Billed: 4440.00
- Allowed: 2400.00
Current A deductible balance: 900.00
Current family deductible balance: 900.00
Out-of-network individual deductible threshold: 3000.00
Family deductible (in-network): 3000.00 — for embedded, the family threshold is 3000.00
Since the service is out-of-network, the deductible threshold is 3000.00 (out-of-network individual). With embedded structure, the individual deductible is satisfied by the lesser of their individual remainder and the family remainder.
A's individual deductible remainder (out-of-network): 3000.00 - 900.00 = 2100.00
Family deductible remainder: 3000.00 - 900.00 = 2100.00
Both are 2100.00, so the deductible applied is min(2100.00, 2100.00, allowed amount 2400.00) = 2100.00.
Wait, let me be more careful. The deductible applied is the lesser of:
- The remaining deductible (individual remainder or family remainder, whichever is less due to embedded)
- The allowed amount of the claim
Individual remainder: 3000.00 - 900.00 = 2100.00
Family remainder: 3000.00 - 900.00 = 2100.00
Lesser of the two: 2100.00
Deductible applied: min(2100.00, 2400.00) = 2100.00
After deductible: 2400.00 - 2100.00 = 300.00
Coinsurance (out-of-network): 40% member / 60% plan
Member coinsurance: 300.00 * 0.40 = 120.00
Plan pays: 300.00 * 0.60 = 180.00
Member responsibility: 2100.00 (deductible) + 120.00 (coinsurance) = 2220.00
Plan paid: 180.00
Check: 2220.00 + 180.00 = 2400.00 ✓
Copay: No copay for a specialist procedure (the copay is for specialist office visit, not a procedure).
Accumulators after Claim 1:
- A deductible: 900.00 + 2100.00 = 3000.00
- A OOPM: 900.00 + 2220.00 = 3120.00
- B deductible: 0.00
- B OOPM: 0.00
- Family deductible: 900.00 + 2100.00 = 3000.00
- Family OOPM: 900.00 + 2220.00 = 3120.00
Wait, but is the deductible fully satisfied now? A's individual out-of-network deductible is 3000.00, and A's balance is now 3000.00. So yes, A's deductible is fully satisfied.
Family deductible is also 3000.00, and family total is 3000.00. So family deductible is also fully satisfied.
**Claim 2 — 2026-05-21 — B (spouse)**
- Service: In-network outpatient imaging
- Network: In-network
- Billed: 2405.00
- Allowed: 1300.00
Current B deductible: 0.00
Current family deductible: 3000.00 (after Claim 1)
Wait, the family deductible is 3000.00 and the family threshold (in-network) is 3000.00. So the family deductible is already met!
With embedded structure, B's individual deductible is satisfied when B's individual credits reach 1500.00 OR when family total reaches 3000.00, whichever comes first.
Family deductible total is 3000.00, which equals the family threshold of 3000.00. So the family deductible is met.
Does this mean B's deductible is also met? In an embedded structure, once the family deductible is met, all members' deductibles are considered met.
So for Claim 2, B's deductible is already met (because the family deductible is met). Let me verify:
B's individual deductible remainder: 1500.00 - 0.00 = 1500.00
Family deductible remainder: 3000.00 - 3000.00 = 0.00
Since the family remainder is 0.00, the deductible is fully met. The deductible applied would be 0.00.
After deductible: 1300.00
Coinsurance (in-network): 20% member / 80% plan
Member coinsurance: 1300.00 * 0.20 = 260.00
Plan pays: 1300.00 * 0.80 = 1040.00
Member responsibility: 0.00 (deductible) + 260.00 (coinsurance) = 260.00
Plan paid: 1040.00
Check: 260.00 + 1040.00 = 1300.00 ✓
Copay: No specific copay for outpatient imaging. It's not a primary care office visit, specialist office visit, urgent care, or emergency room. So no copay.
Accumulators after Claim 2:
- A deductible: 3000.00 (unchanged)
- A OOPM: 3120.00 (unchanged)
- B deductible: 0.00 + 0.00 = 0.00 (no deductible applied)
- B OOPM: 0.00 + 260.00 = 260.00
- Family deductible: 3000.00 (unchanged, no deductible applied)
- Family OOPM: 3120.00 + 260.00 = 3380.00
**Claim 3 — 2026-06-14 — A (subscriber)**
- Service: In-network follow-up procedure
- Network: In-network
- Billed: 3330.00
- Allowed: 1800.00
Current A deductible: 3000.00
Current family deductible: 3000.00
A's individual in-network deductible: 1500.00 — already met (3000.00 > 1500.00)
Family in-network deductible: 3000.00 — already met (3000.00 = 3000.00)
So no deductible applies. The entire allowed amount goes to coinsurance.
Coinsurance (in-network): 20% member / 80% plan
Member coinsurance: 1800.00 * 0.20 = 360.00
Plan pays: 1800.00 * 0.80 = 1440.00
Member responsibility: 0.00 (deductible) + 360.00 (coinsurance) = 360.00
Plan paid: 1440.00
Check: 360.00 + 1440.00 = 1800.00 ✓
Copay: No specific copay for a follow-up procedure.
Accumulators after Claim 3:
- A deductible: 3000.00 (unchanged)
- A OOPM: 3120.00 + 360.00 = 3480.00
- B deductible: 0.00 (unchanged)
- B OOPM: 260.00 (unchanged)
- Family deductible: 3000.00 (unchanged)
- Family OOPM: 3380.00 + 360.00 = 3740.00
**Claim 4 — 2026-07-08 — A (subscriber)**
- Service: Out-of-network diagnostic study
- Network: Out-of-network
- Billed: 2960.00
- Allowed: 1600.00
Current A deductible: 3000.00
Current family deductible: 3000.00
A's individual out-of-network deductible: 3000.00 — already met (3000.00 = 3000.00)
Family deductible: 3000.00 — already met (3000.00 = 3000.00)
So no deductible applies. The entire allowed amount goes to coinsurance.
Wait, but let me double-check. A's deductible balance is 3000.00. The out-of-network individual threshold is 3000.00. So A has met the out-of-network deductible. The family deductible is also 3000.00, which is met.
So no deductible applies.
After deductible: 1600.00
Coinsurance (out-of-network): 40% member / 60% plan
Member coinsurance: 1600.00 * 0.40 = 640.00
Plan pays: 1600.00 * 0.60 = 960.00
Member responsibility: 0.00 (deductible) + 640.00 (coinsurance) = 640.00
Plan paid: 960.00
Check: 640.00 + 960.00 = 1600.00 ✓
Copay: No specific copay for a diagnostic study.
Now let me check OOPM. A's current OOPM before Claim 4 is 3480.00. The individual in-network OOPM is 6000.00 and individual out-of-network OOPM is 12000.00. Since 3480.00 < 6000.00, A hasn't reached the OOPM, so coinsurance applies normally.
Wait, I need to be careful about the OOPM for out-of-network services. The individual out-of-network OOPM is 12000.00. But I also need to consider whether the in-network OOPM applies differently.
Actually, let me re-read: "Individual (in-network) OOPM: 6000.00" and "Individual (out-of-network) OOPM: 12000.00".
Hmm, but similar to the deductible, is there a single OOPM balance or separate ones? The plan document says for the deductible that IN and ON credits accumulate to a single balance. But it doesn't say the same for OOPM.
Let me re-read: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year."
And the OOPM section says:
- Individual (in-network): 6000.00
- Family (in-network): 12000.00
- Individual (out-of-network): 12000.00
It doesn't mention whether the OOPM has a single balance or separate balances. Given that the deductible section explicitly says IN and ON credits accumulate to a single balance, but the OOPM section doesn't say this, I'm uncertain. However, the typical approach in most plans is that OOPM is a single balance too (combining IN and ON). Let me assume that.
So A's OOPM balance is 3480.00 (combining all cost share). The OOPM thresholds are:
- In-network: 6000.00
- Out-of-network: 12000.00
When A gets an out-of-network service, the OOPM threshold is 12000.00. Since 3480.00 < 12000.00, A hasn't reached the OOPM, so coinsurance applies normally.
Member coinsurance: 640.00
A's new OOPM: 3480.00 + 640.00 = 4120.00
Accumulators after Claim 4:
- A deductible: 3000.00 (unchanged, no deductible applied)
- A OOPM: 3480.00 + 640.00 = 4120.00
- B deductible: 0.00 (unchanged)
- B OOPM: 260.00 (unchanged)
- Family deductible: 3000.00 (unchanged)
- Family OOPM: 3740.00 + 640.00 = 4380.00
Let me now summarize the Claim 4 results:
**Claim 4:**
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
**Ending accumulators:**
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
Wait, let me double-check by re-computing all the OOPM changes:
Starting:
- A OOPM: 900.00
- B OOPM: 0.00
- Family OOPM: 900.00
Claim 1 (A, OON, procedure):
- Deductible: 2100.00
- Coinsurance (40%): 120.00
- Member responsibility: 2220.00
- A OOPM: 900.00 + 2220.00 = 3120.00
- Family OOPM: 900.00 + 2220.00 = 3120.00
Claim 2 (B, IN, imaging):
- Deductible: 0.00 (family deductible met)
- Coinsurance (20%): 260.00
- Member responsibility: 260.00
- B OOPM: 0.00 + 260.00 = 260.00
- Family OOPM: 3120.00 + 260.00 = 3380.00
Claim 3 (A, IN, follow-up):
- Deductible: 0.00 (individual and family deductible met)
- Coinsurance (20%): 360.00
- Member responsibility: 360.00
- A OOPM: 3120.00 + 360.00 = 3480.00
- Family OOPM: 3380.00 + 360.00 = 3740.00
Claim 4 (A, OON, diagnostic):
- Deductible: 0.00 (individual OON deductible met at 3000.00, family deductible met at 3000.00)
- Coinsurance (40%): 640.00
- Member responsibility: 640.00
- A OOPM: 3480.00 + 640.00 = 4120.00
- Family OOPM: 3740.00 + 640.00 = 4380.00
This all checks out. Let me also verify the deductible calculations one more time.
Starting:
- A deductible: 900.00
- B deductible: 0.00
- Family deductible: 900.00
Claim 1 (A, OON):
- Individual OON deductible threshold: 3000.00
- A individual remainder: 3000.00 - 900.00 = 2100.00
- Family remainder: 3000.00 - 900.00 = 2100.00
- Embedded: lesser of 2100.00 and 2100.00 = 2100.00
- Deductible applied: min(2100.00, 2400.00) = 2100.00
- A deductible: 900.00 + 2100.00 = 3000.00
- Family deductible: 900.00 + 2100.00 = 3000.00
Claim 2 (B, IN):
- Individual IN deductible threshold: 1500.00
- B individual remainder: 1500.00 - 0.00 = 1500.00
- Family remainder: 3000.00 - 3000.00 = 0.00
- Embedded: lesser of 1500.00 and 0.00 = 0.00
- Deductible applied: min(0.00, 1300.00) = 0.00
- B deductible: 0.00 + 0.00 = 0.00
- Family deductible: 3000.00 + 0.00 = 3000.00
Claim 3 (A, IN):
- A individual remainder: 1500.00 - 3000.00 = negative (already met)
- Actually, A's deductible balance is 3000.00, which exceeds the IN individual threshold of 1500.00. So A's individual deductible is met.
- Family remainder: 3000.00 - 3000.00 = 0.00
- Deductible applied: 0.00
- A deductible: 3000.00 (unchanged)
- Family deductible: 3000.00 (unchanged)
Claim 4 (A, OON):
- A's deductible balance: 3000.00
- OON individual threshold: 3000.00
- A individual remainder: 3000.00 - 3000.00 = 0.00 (met)
- Family remainder: 3000.00 - 3000.00 = 0.00 (met)
- Deductible applied: 0.00
- A deductible: 3000.00 (unchanged)
- Family deductible: 3000.00 (unchanged)
All checks out.
Final answer:
Claim 4:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
Ending accumulators:
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
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"field": "member_responsibility",
"want": 640,
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{
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],
"fabricated": false,
"abstained": false
}Reasoning · 5,311 tokens
Let me work through this step by step.
Starting accumulators (before Claim 1):
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family: deductible 900.00, OOPM 900.00
Plan details:
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00
- Out-of-network individual deductible: 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
- Structure: EMBEDDED
- Individual in-network OOPM: 6000.00
- Family in-network OOPM: 12000.00
- Individual out-of-network OOPM: 12000.00
- Coinsurance after deductible, in-network: 20% member / 80% plan
- Coinsurance after deductible, out-of-network: 40% member / 60% plan
- Copays don't credit deductible, but do credit OOPM.
Wait, the deductible is embedded. So each individual has their own individual deductible. The individual in-network deductible is 1500.00. The out-of-network individual deductible threshold is 3000.00. But the credits accumulate to a single member deductible balance.
Wait, let me re-read: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So there's a single deductible balance per member. When the service is in-network, the threshold is 1500.00 (individual) or 3000.00 (family). When the service is out-of-network, the threshold is 3000.00 (individual).
So for A, starting deductible balance is 900.00. For in-network services, the threshold is 1500.00. For out-of-network services, the threshold is 3000.00.
The embedded structure means: an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
So under embedded, when a member's individual deductible is met, the plan starts paying coinsurance for that member. The family deductible is met when total family credits reach 3000.00.
But there's a nuance with the out-of-network threshold. Let me think about this.
Actually, let me re-read: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
So the individual deductible for in-network is 1500.00. For out-of-network, the threshold is 3000.00. The credits accumulate to a single balance.
So if A has 900.00 in deductible credits:
- For an in-network service, the threshold is 1500.00, so A needs 600.00 more to meet the individual deductible.
- For an out-of-network service, the threshold is 3000.00, so A needs 2100.00 more to meet the individual out-of-network deductible.
Wait, but the family deductible is 3000.00 in-network. The out-of-network family threshold isn't explicitly stated... Let me check. The document says "Family (in-network) .... 3000.00" and "Out-of-network (individual) .... 3000.00". There's no out-of-network family deductible explicitly listed. Hmm.
Actually, looking at the structure: the single member deductible balance is measured against the in-network threshold (1500.00 individual) or the out-of-network threshold (3000.00 individual) depending on the service. For the family, the family deductible is 3000.00 (in-network).
Let me think about how this works for each claim.
Claim 1 — 2026-05-05 — A (subscriber)
- Out-of-network specialist procedure
- Allowed amount: 2400.00
- A's deductible balance: 900.00
- Out-of-network individual threshold: 3000.00
- Family deductible total: 900.00, family threshold: 3000.00
Since this is out-of-network, A's individual deductible threshold is 3000.00. A has 900.00 credited. Remaining to meet individual OON deductible: 3000.00 - 900.00 = 2100.00.
The allowed amount is 2400.00. Since 2400.00 > 2100.00, the deductible portion is 2100.00, and the remaining 300.00 goes to coinsurance.
Wait, but we also need to check the family deductible. Under embedded, the individual satisfies the individual deductible on their own. But with out-of-network, the individual threshold is 3000.00.
Hmm, but actually, the embedded structure says "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
I think the key issue is: when the service is out-of-network, the individual deductible threshold is 3000.00, not 1500.00. So for out-of-network services, A needs to meet the 3000.00 threshold before coinsurance kicks in.
But wait, the family deductible is stated as 3000.00 in-network. Is the family deductible also 3000.00 for out-of-network? The document doesn't explicitly state an out-of-network family deductible. But since the single balance is measured against the threshold "when the service is out-of-network," and the only out-of-network threshold listed is the individual one at 3000.00...
Actually, let me think about this differently. The deductible section says:
- Individual (in-network): 1500.00
- Family (in-network): 3000.00
- Out-of-network (individual): 3000.00
- Structure: EMBEDDED
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
So when a service is out-of-network, the member's deductible balance is measured against 3000.00 (the out-of-network individual threshold). When in-network, it's measured against 1500.00 (individual) or 3000.00 (family).
For the family, the in-network family deductible is 3000.00. There's no separate out-of-network family deductible listed, but the embedded structure says the family deductible is satisfied when total family credits reach the family amount. I think the family amount is 3000.00 regardless.
But here's the thing: under the embedded structure, for out-of-network services, does the individual threshold become 3000.00? And the family threshold stays 3000.00? That would mean the individual OON threshold equals the family threshold, which seems odd but that's what the document says.
Actually, let me reconsider. The embedded rule says "an individual satisfies the individual deductible on their own." The individual deductible in-network is 1500.00 and out-of-network is 3000.00. The family deductible is 3000.00.
For out-of-network services, the individual must meet the 3000.00 threshold. Under embedded, the individual's deductible is satisfied when their own balance reaches their individual threshold. But also, the family deductible is satisfied when total family credits reach the family amount (3000.00), whichever comes first.
So for Claim 1 (A, out-of-network):
- A's deductible balance: 900.00
- OON individual threshold: 3000.00
- Remaining individual: 3000.00 - 900.00 = 2100.00
- Family total: 900.00, family threshold: 3000.00
- Remaining family: 3000.00 - 900.00 = 2100.00
The allowed amount is 2400.00. The deductible that can be applied is the lesser of:
- The individual remaining: 2100.00
- The family remaining: 2100.00
- The allowed amount: 2400.00
So deductible applied = 2100.00. This satisfies both A's individual OON deductible and the family deductible.
After deductible: 2400.00 - 2100.00 = 300.00 goes to coinsurance.
Out-of-network coinsurance: 40% member / 60% plan.
Member coinsurance: 300.00 * 0.40 = 120.00
Plan paid: 300.00 * 0.60 = 180.00
Member responsibility: 2100.00 (deductible) + 120.00 (coinsurance) = 2220.00
Plan paid: 180.00
Total: 2220.00 + 180.00 = 2400.00 ✓
Accumulator updates after Claim 1:
- A deductible: 900.00 + 2100.00 = 3000.00
- A OOPM: 900.00 + 2100.00 + 120.00 = 3120.00
- B deductible: 0.00
- B OOPM: 0.00
- Family deductible: 900.00 + 2100.00 = 3000.00
- Family OOPM: 900.00 + 2220.00 = 3120.00
Now, A's individual deductible is met (3000.00 ≥ 3000.00 OON threshold). The family deductible is also met (3000.00 ≥ 3000.00).
Claim 2 — 2026-05-21 — B (spouse)
- In-network outpatient imaging
- Allowed amount: 1300.00
- B's deductible balance: 0.00
- In-network individual threshold: 1500.00
- Family deductible: 3000.00 (already met!)
Since the family deductible is already met (3000.00), under embedded structure, does B need to meet their individual deductible?
The embedded rule says: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
So the family deductible is already satisfied. Under embedded, once the family deductible is met, does that mean all family members have their deductible met? Or does each individual still need to meet their own individual deductible?
In a typical embedded deductible structure, each individual has their own individual deductible embedded within the family deductible. The family deductible is met when total family credits reach the family amount. But an individual can also meet their own individual deductible independently.
The key question is: once the family deductible is met, does the plan start paying coinsurance for ALL family members, or only for the member who met their individual deductible?
In a standard embedded deductible plan, once the family deductible is met, all family members are considered to have met their deductible. The "whichever comes first" language supports this: the family deductible being satisfied means coinsurance starts for all members.
Actually, let me re-read: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
So there are two ways a member's deductible can be satisfied:
1. The individual meets their own individual deductible.
2. The family deductible is satisfied (total family credits reach family amount).
"Whichever comes first" means whichever threshold is reached first.
For B: B's individual deductible balance is 0.00, so B hasn't met their individual deductible. But the family deductible is already met (3000.00 ≥ 3000.00). So B's deductible is satisfied via the family deductible being met.
Therefore, for Claim 2, B's deductible is already met (through family), so the entire allowed amount goes to coinsurance.
Wait, but that's the standard embedded deductible interpretation. But let me think about whether there's a subtlety with the out-of-network threshold.
The family deductible was met through A's out-of-network claim. The family deductible is 3000.00 (in-network). A's OON individual threshold is also 3000.00. So when A met 3000.00, both A's individual OON deductible and the family deductible were met simultaneously.
For B, the family deductible is met, so B's deductible is satisfied. B's service is in-network, so coinsurance is 20% member / 80% plan.
Claim 2:
- Allowed amount: 1300.00
- Deductible applied: 0.00 (family deductible already met)
- Coinsurance: 1300.00 * 20% = 260.00 member, 1300.00 * 80% = 1040.00 plan
- Member responsibility: 260.00
- Plan paid: 1040.00
Accumulator updates after Claim 2:
- A deductible: 3000.00 (no change)
- A OOPM: 3120.00 (no change)
- B deductible: 0.00 (no deductible applied, but family is met - B's individual balance stays 0.00? Or does it get credited?)
Wait, the deductible balance is the amount the member has paid toward their deductible. Since no deductible was applied for B, B's deductible balance stays 0.00. But B's deductible is considered satisfied because the family deductible is met.
- B deductible: 0.00 (no deductible applied to this claim)
- B OOPM: 0.00 + 260.00 = 260.00
- Family deductible: 3000.00 (no change, already met)
- Family OOPM: 3120.00 + 260.00 = 3380.00
Claim 3 — 2026-06-14 — A (subscriber)
- In-network follow-up procedure
- Allowed amount: 1800.00
- A's deductible balance: 3000.00 (already met individual OON threshold of 3000.00 and family deductible)
Since A's deductible is already met, the entire amount goes to coinsurance.
- In-network coinsurance: 20% member / 80% plan
- Member coinsurance: 1800.00 * 20% = 360.00
- Plan paid: 1800.00 * 80% = 1440.00
- Member responsibility: 360.00
Accumulator updates after Claim 3:
- A deductible: 3000.00 (no change)
- A OOPM: 3120.00 + 360.00 = 3480.00
- B deductible: 0.00
- B OOPM: 260.00
- Family deductible: 3000.00
- Family OOPM: 3380.00 + 360.00 = 3740.00
Claim 4 — 2026-07-08 — A (subscriber)
- Out-of-network diagnostic study
- Allowed amount: 1600.00
- A's deductible balance: 3000.00 (already met)
- A's OOPM: 3480.00
Deductible is already met. Entire amount goes to coinsurance.
- Out-of-network coinsurance: 40% member / 60% plan
- Member coinsurance: 1600.00 * 40% = 640.00
- Plan paid: 1600.00 * 60% = 960.00
- Member responsibility: 640.00
Check OOPM: A's OOPM after this claim: 3480.00 + 640.00 = 4120.00. Individual in-network OOPM is 6000.00, individual out-of-network OOPM is 12000.00. Since this is an out-of-network service, the OOPM threshold is 12000.00. 4120.00 < 12000.00, so no OOPM reached.
Wait, but there's a question about which OOPM threshold applies. The plan says:
- Individual (in-network) OOPM: 6000.00
- Family (in-network) OOPM: 12000.00
- Individual (out-of-network) OOPM: 12000.00
Hmm, but do in-network and out-of-network OOPM credits accumulate to a single balance? The plan doesn't explicitly say that for OOPM like it does for deductible. Let me re-read.
The deductible section says: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
There's no similar statement for OOPM. But typically, OOPM accumulates across both in-network and out-of-network. However, the plan document doesn't explicitly say this for OOPM.
Actually, the OOPM section says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It doesn't specify separate in-network and out-of-network OOPM accumulators.
Given the plan lists separate in-network and out-of-network OOPM amounts, but the deductible section explicitly mentions a single balance for deductible, I think the OOPM might work similarly - there's a single OOPM balance, but the threshold depends on the service type. For in-network, the individual threshold is 6000.00; for out-of-network, it's 12000.00.
Actually wait, that doesn't quite make sense. Let me reconsider.
Typically, in many plans, there's a single OOPM and the in-network and out-of-network amounts might be different thresholds. But the plan says "Once a member reaches the out-of-pocket maximum the plan pays 100%." This suggests a single OOPM concept.
Given the deductible explicitly states single balance with different thresholds, I'll assume OOPM works similarly: single balance, with the threshold being 6000.00 for in-network and 12000.00 for out-of-network services. But actually, the family OOPM is 12000.00 in-network and individual OON OOPM is 12000.00. That's a lot.
For Claim 4, A's OOPM before the claim is 3480.00. The OON OOPM threshold is 12000.00. So 3480.00 + 640.00 = 4120.00, which is well below 12000.00. No issue.
But wait, I need to think about whether the in-network OOPM (6000.00) could have been reached. A's OOPM is 3480.00 before Claim 4. Even if the in-network threshold of 6000.00 applies, 3480.00 + 640.00 = 4120.00 < 6000.00. So no OOPM reached regardless.
Let me also reconsider the family OOPM. Family OOPM (in-network) is 12000.00. Family OOPM before Claim 4 is 3740.00. After Claim 4: 3740.00 + 640.00 = 4380.00. Well below 12000.00.
So for Claim 4:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
Ending accumulators:
- A deductible: 3000.00
- A OOPM: 4120.00
- B deductible: 0.00
- B OOPM: 260.00
- Family deductible: 3000.00
- Family OOPM: 4380.00
Wait, let me double-check all the calculations again.
Claim 1 — A, OON specialist procedure, allowed 2400.00
- A deductible balance before: 900.00
- OON individual threshold: 3000.00
- Family deductible before: 900.00, family threshold: 3000.00
- Individual remaining: 3000.00 - 900.00 = 2100.00
- Family remaining: 3000.00 - 900.00 = 2100.00
- Deductible applied: min(2100.00, 2100.00, 2400.00) = 2100.00
- After deductible: 2400.00 - 2100.00 = 300.00
- OON coinsurance: 40% member = 120.00, 60% plan = 180.00
- MR: 2100.00 + 120.00 = 2220.00
- Plan paid: 180.00
- A deductible after: 900.00 + 2100.00 = 3000.00
- A OOPM after: 900.00 + 2220.00 = 3120.00
- Family deductible after: 900.00 + 2100.00 = 3000.00
- Family OOPM after: 900.00 + 2220.00 = 3120.00
Claim 2 — B, INN outpatient imaging, allowed 1300.00
- B deductible balance before: 0.00
- Family deductible already met (3000.00)
- Under embedded, family deductible met means B's deductible is satisfied
- Deductible applied: 0.00
- After deductible: 1300.00
- INN coinsurance: 20% member = 260.00, 80% plan = 1040.00
- MR: 260.00
- Plan paid: 1040.00
- B deductible after: 0.00 (no deductible applied)
- B OOPM after: 0.00 + 260.00 = 260.00
- Family deductible after: 3000.00 (no change)
- Family OOPM after: 3120.00 + 260.00 = 3380.00
Claim 3 — A, INN follow-up procedure, allowed 1800.00
- A deductible already met (3000.00)
- Deductible applied: 0.00
- INN coinsurance: 20% member = 360.00, 80% plan = 1440.00
- MR: 360.00
- Plan paid: 1440.00
- A deductible after: 3000.00
- A OOPM after: 3120.00 + 360.00 = 3480.00
- Family deductible after: 3000.00
- Family OOPM after: 3380.00 + 360.00 = 3740.00
Claim 4 — A, OON diagnostic study, allowed 1600.00
- A deductible already met (3000.00)
- Deductible applied: 0.00
- OON coinsurance: 40% member = 640.00, 60% plan = 960.00
- MR: 640.00
- Plan paid: 960.00
- A deductible after: 3000.00
- A OOPM after: 3480.00 + 640.00 = 4120.00
- B deductible: 0.00
- B OOPM: 260.00
- Family deductible after: 3000.00
- Family OOPM after: 3740.00 + 640.00 = 4380.00
Let me verify: member_responsibility (640.00) + plan_paid (960.00) = 1600.00 = allowed amount ✓
Final answer:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
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"field": "member_responsibility",
"want": 640,
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"ok": true,
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"got": 960,
"ok": true,
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},
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"want": 0,
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},
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"want": 0,
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"ok": true,
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"field": "ending_family_deductible",
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"ok": true,
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"want": 4380,
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{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
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},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
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"want": 260,
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"ok": true,
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],
"fabricated": false,
"abstained": false
}100Claude Opus 4.8 · Anthropic11.7s · 1,039 out | 13.1s · 1,094 out | 16.1s · 1,344 out
Let me work through each claim.
**Initial:** A ded 900, oop 900; B ded 0, oop 0; Family ded 900, oop 900.
**Claim 1 — A, OON specialist, allowed 2400.**
A deductible balance 900. OON individual deductible threshold 3000. Member remainder = 3000-900=2100. Family: embedded, family ded 3000, family total 900, remainder 2100. Deductible applied = lesser(2100, 2100, 2400)=2100.
Remaining after deductible = 2400-2100=300. OON coinsurance 40% = 120. Plan 60% = 180.
Member responsibility = 2100+120=2220.
A ded: 900+2100=3000. A oop: 900+2220=3120. (OON OOPM is 12000, fine.)
Family ded: 900+2100=3000. Family oop: 900+2220=3120.
**Claim 2 — B, in-network imaging, allowed 1300.**
B deductible balance 0. Family deductible already at 3000 (satisfied). Embedded: family ded satisfied means... individual deductible for B — under embedded, individual satisfied on own OR family satisfied. Family is at 3000 (satisfied), so B's deductible is considered met.
Deductible applied = 0. Coinsurance 20% = 260. Plan 80% = 1040.
Member responsibility = 260.
B ded: 0. B oop: 0+260=260.
Family ded: 3000. Family oop: 3120+260=3380.
**Claim 3 — A, in-network follow-up, allowed 1800.**
A deductible already 3000 (met). Deductible applied 0. Coinsurance 20% = 360. Plan 1440.
A oop before: 3120. +360=3480 (< 6000).
Member responsibility = 360.
A oop: 3480. Family oop: 3380+360=3740.
**Claim 4 — A, OON diagnostic, allowed 1600.**
A deductible balance 3000 (single balance, met). Deductible applied 0.
OON coinsurance 40% = 640. Plan 60% = 960.
A OON OOPM 12000; A oop 3480+640=4120 < 12000. Fine.
Member responsibility = 640. Plan_paid = 960.
Coinsurance = 640. Copay 0. Deductible 0.
Ending A: ded 3000, oop 4120.
Ending B: ded 0, oop 260.
Family ded 3000, family oop 3740+640=4380.
json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "4120.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3000.00",
"ending_family_oopm": "4380.00"
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
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},
{
"field": "plan_paid",
"want": 960,
"got": "960.00",
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
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},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4380.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Let me work through each claim.
**Starting:** A ded 900, oop 900; B ded 0, oop 0; Family ded 900, oop 900.
**Claim 1 — A, OON specialist, allowed 2400.**
OON deductible threshold 3000, single member balance. A's balance = 900. Remaining ded = 1500? No—OON uses 3000 threshold. A's ded balance is 900, measured against 3000 for OON.
Deductible applied: A owes up to remaining. A single balance 900, family embedded.
A's individual OON threshold 3000, remaining = 3000-900 = 2100. Family remaining = 3000-900=2100. Lesser = 2100. Allowed 2400, so 2100 goes to deductible.
Remaining 300 after deductible → coinsurance 40% = 120 member, 180 plan.
Member = 2100 + 120 = 2220.
A ded: 900+2100 = 3000. A oop: 900+2220 = 3120.
Family ded: 900+2100 = 3000. Family oop: 900+2220 = 3120.
**Claim 2 — B, in-network imaging, allowed 1300.**
Family deductible now 3000 → satisfied (family threshold 3000 reached). Under embedded, family deductible satisfied once family credits reach 3000. So no more deductible for anyone.
So B pays coinsurance 20%: 1300*0.20 = 260 member, 1040 plan.
B ded: 0 (no deductible applied). B oop: 260.
Family ded: 3000. Family oop: 3120+260 = 3380.
Wait—B's individual deductible not met but family is met (embedded: family met means plan pays for everyone). Yes.
**Claim 3 — A, in-network follow-up, allowed 1800.**
Family ded met. A coinsurance 20%: 1800*0.20 = 360 member, 1440 plan.
Check A oop: 3120+360 = 3480, under 6000.
A ded stays 3000. A oop: 3480.
Family oop: 3380+360 = 3740.
**Claim 4 — A, OON diagnostic, allowed 1600.**
Family ded met (3000). A ded met. So no deductible.
OON coinsurance 40%: 1600*0.40 = 640 member, 960 plan.
Check A OON oop max 12000, A oop = 3480+640=4120, fine.
Member = 640, plan = 960.
Deductible applied 0, copay 0, coinsurance 640.
A ded: 3000. A oop: 4120.
B ded: 0. B oop: 260.
Family ded: 3000. Family oop: 3740+640 = 4380.
json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "4120.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3000.00",
"ending_family_oopm": "4380.00"
}
Grader detail
json{
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{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
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},
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"want": 960,
"got": "960.00",
"ok": true,
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},
{
"field": "deductible_applied",
"want": 0,
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"ok": true,
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},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
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},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4380.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Let me work through each claim.
**Starting accumulators:**
- A: deductible 900, oopm 900
- B: deductible 0, oopm 0
- Family: deductible 900, oopm 900
Note: single member deductible balance for in/out network. Individual deductible threshold: 1500 in-network, 3000 out-of-network. Embedded: family 3000.
**Claim 1 — A, OON specialist, allowed 2400**
A's deductible balance = 900. OON threshold = 3000. So member still in deductible.
Remaining to OON deductible: individual remainder = 3000-900=2100; family remainder = 3000-900=2100. Lesser = 2100.
Allowed 2400. Deductible applied = min(2400, 2100) = 2100.
After deductible: remaining allowed = 300, coinsurance 40% = 120.
Member = 2100 + 120 = 2220. Plan = 2400-2220 = 180.
Check OON OOPM: A oopm 900 → +2220 = 3120 (< 12000). OK.
Update A: deductible = 900+2100 = 3000. oopm = 900+2220 = 3120.
Family: deductible = 900+2100 = 3000. oopm = 900+2220 = 3120.
**Claim 2 — B, in-network imaging, allowed 1300**
B deductible balance = 0. In-network individual threshold 1500.
Family deductible already at 3000 (met). Embedded: family deductible satisfied → does that pay for any member? Family deductible met means plan pays for members after family deductible.
Wait — family deductible satisfied once family credits reach 3000. Family = 3000 now. So family deductible is satisfied. Under embedded, once family deductible met, all members' deductibles considered met.
So B's deductible is satisfied via family. Deductible applied = 0 for B.
Coinsurance 20% on 1300 = 260. Member = 260, plan = 1040.
Check B oopm: 0 → 260 (< 6000). Family oopm 3120+260=3380 (<12000). OK.
Update B: deductible = 0 (no credit needed, but let's keep 0). oopm = 260.
Family: deductible stays 3000. oopm = 3380.
**Claim 3 — A, in-network procedure, allowed 1800**
A deductible met (3000, family met). Coinsurance 20% = 360.
Member = 360, plan = 1440.
A oopm: 3120 → 3480. Family oopm: 3380 → 3740. OK.
Update A: oopm = 3480. Family oopm = 3740.
**Claim 4 — A, OON diagnostic, allowed 1600**
A deductible balance = 3000. OON threshold = 3000, met. Deductible applied = 0.
Coinsurance OON 40% = 1600*0.40 = 640.
Member = 640, plan = 960.
Check OON OOPM: A OON oopm threshold = 12000. A oopm 3480 → 4120. Family oopm 3740→4380. OK.
Update A: oopm = 4120. Family oopm = 4380.
A deductible = 3000. Family deductible 3000.
B deductible 0, oopm 260.
**Claim 4 components:**
- member_responsibility = 640.00
- plan_paid = 960.00
- deductible_applied = 0.00
- copay_amount = 0.00
- coinsurance_amount = 640.00
json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "4120.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3000.00",
"ending_family_oopm": "4380.00"
}
Grader detail
json{
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{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
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},
{
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"want": 960,
"got": "960.00",
"ok": true,
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},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
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},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
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},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4380.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Qwen3.7 Max · Alibaba154.2s · 8,974 out | 741.0s · 8,085 out | 131.5s · 11,633 out
Reasoning · 8,787 tokens
Let me work through this step by step.
**Plan Document Summary:**
- Individual deductible (in-network): 1500.00
- Family deductible (in-network): 3000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance, measured against the out-of-network threshold when service is out-of-network.
- Individual OOPM (in-network): 6000.00
- Family OOPM (in-network): 12000.00
- Individual OOPM (out-of-network): 12000.00
- Coinsurance after deductible, in-network: 20% member / 80% plan
- Coinsurance after deductible, out-of-network: 40% member / 60% plan
- Copays do NOT credit the deductible. Copays always credit the OOPM.
**Starting Accumulators:**
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family: deductible 900.00, OOPM 900.00
---
**Claim 1 — 2026-05-05 — A (subscriber)**
- Out-of-network specialist procedure
- Billed: 4440.00, Allowed: 2400.00
- Network: Out-of-network
For out-of-network services, the deductible threshold is 3000.00 (individual out-of-network deductible).
A's current deductible accumulator: 900.00
Remaining to meet out-of-network deductible: 3000.00 - 900.00 = 2100.00
Allowed amount: 2400.00
Deductible applied: min(2400.00, 2100.00) = 2100.00
Remaining allowed after deductible: 2400.00 - 2100.00 = 300.00
Coinsurance (out-of-network): 40% member / 60% plan
Coinsurance amount: 300.00 * 0.40 = 120.00
Plan paid (coinsurance portion): 300.00 * 0.60 = 180.00
Member responsibility: deductible_applied + coinsurance_amount = 2100.00 + 120.00 = 2220.00
Plan paid: 180.00
Check: member_responsibility + plan_paid = 2220.00 + 180.00 = 2400.00 ✓
Update accumulators for A:
- A deductible: 900.00 + 2100.00 = 3000.00
- A OOPM: 900.00 + 2220.00 = 3120.00
- Family deductible: 900.00 + 2100.00 = 3000.00
- Family OOPM: 900.00 + 2220.00 = 3120.00
Wait, I need to think about the family deductible. The family deductible is 3000.00 (in-network). But A's service is out-of-network. Let me re-read the plan document.
"In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So there's a single member deductible balance. The threshold depends on the network status of the current service:
- If in-network: threshold is 1500.00
- If out-of-network: threshold is 3000.00
For the family deductible, the plan says:
- Family (in-network): 3000.00
What about the family deductible for out-of-network? The plan doesn't explicitly state a separate out-of-network family deductible. Let me re-read...
The plan says:
- Family (in-network): 3000.00
- Structure: EMBEDDED
There's no separate out-of-network family deductible mentioned. The family deductible is 3000.00.
Actually wait - the embedded structure says "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
So the family deductible is 3000.00. Credits from both in-network and out-of-network accumulate to it.
A's deductible credits: 2100.00 added.
A's individual deductible balance: 900.00 + 2100.00 = 3000.00
Family deductible: 900.00 + 2100.00 = 3000.00
Now, has A satisfied the individual deductible for out-of-network purposes? A's balance is 3000.00, and the out-of-network threshold is 3000.00. Yes, A has met the out-of-network deductible.
Has the family deductible been met? Family total is 3000.00, and family deductible is 3000.00. Yes.
Now, since A's deductible balance is 3000.00 (which meets the out-of-network threshold of 3000.00), A's individual deductible is satisfied for out-of-network.
And since family deductible is 3000.00 = 3000.00, family deductible is also satisfied.
So for Claim 1:
- Deductible applied: 2100.00
- Coinsurance on remaining 300.00 at 40%: 120.00
- Member responsibility: 2220.00
- Plan paid: 180.00
Accumulators after Claim 1:
- A: deductible 3000.00, OOPM 3120.00
- B: deductible 0.00, OOPM 0.00
- Family: deductible 3000.00, OOPM 3120.00
---
**Claim 2 — 2026-05-21 — B (spouse)**
- In-network outpatient imaging
- Billed: 2405.00, Allowed: 1300.00
- Network: In-network
For in-network services, the individual deductible threshold is 1500.00.
B's current deductible accumulator: 0.00
Remaining to meet in-network deductible: 1500.00 - 0.00 = 1500.00
But wait - the family deductible is already met (3000.00). Under embedded structure, does that mean B's deductible is also satisfied?
The embedded structure says: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
So the family deductible being satisfied means... what exactly? It means the family deductible is met. But does it mean each individual's deductible is also met?
Under embedded deductible: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
I think "whichever comes first" means:
1. An individual can satisfy their own individual deductible independently, OR
2. The family deductible is satisfied once total family credits reach the family amount.
Once the family deductible is satisfied, all members are considered to have met their deductible. That's the standard interpretation of embedded deductibles.
Actually, let me think about this more carefully. In a typical embedded deductible structure:
- Each person has an individual deductible
- The family has a family deductible
- Once an individual meets their individual deductible, coinsurance kicks in for that person
- Once the family deductible is met, all family members have their deductibles considered met
So if the family deductible is 3000.00 and it's been met (from A's 2100.00 + previous 900.00 = 3000.00), then B's deductible should be considered met.
Wait, but B has 0.00 in deductible credits. If the family deductible is met, does B get to skip the deductible entirely?
In standard embedded deductible structures, yes - once the family deductible is met, all members are treated as having met their deductible.
Let me reconsider. The plan says: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
This means:
- Path 1: Individual meets their own deductible → that individual gets coinsurance
- Path 2: Family total credits reach family amount → family deductible is met → all members get coinsurance
Since family deductible (3000.00) has been reached, B's deductible is considered met.
So for Claim 2 (B, in-network):
- Deductible applied: 0.00 (family deductible already met)
- Coinsurance (in-network): 20% member / 80% plan
- Allowed: 1300.00
- Coinsurance amount: 1300.00 * 0.20 = 260.00
- Plan paid: 1300.00 * 0.80 = 1040.00
- Member responsibility: 260.00
Check: 260.00 + 1040.00 = 1300.00 ✓
Update accumulators:
- B deductible: 0.00 + 0.00 = 0.00 (no deductible applied)
Wait, but does B's deductible accumulator get credited? If the deductible is already met via family, does B still accumulate deductible credits?
Hmm, actually the deductible was not applied because the family deductible was already met. So B's deductible balance stays at 0.00. But wait - does B's deductible balance need to be tracked separately?
Actually, let me reconsider the whole embedded deductible logic more carefully.
Under embedded deductible:
- Each member has their own individual deductible balance
- There's also a family deductible balance
- When a claim comes in, we check: has this member met their individual deductible? OR has the family met the family deductible?
- If either is true, the deductible is considered satisfied for this member
For B:
- B's individual deductible balance: 0.00 (has not met 1500.00 threshold)
- Family deductible balance: 3000.00 (has met 3000.00 threshold)
- Since family deductible is met, B's deductible is considered satisfied
So for Claim 2:
- Deductible applied: 0.00
- Coinsurance: 20% of 1300.00 = 260.00
- Member responsibility: 260.00
- Plan paid: 1040.00
Accumulators after Claim 2:
- A: deductible 3000.00, OOPM 3120.00
- B: deductible 0.00, OOPM 0.00 + 260.00 = 260.00
- Family: deductible 3000.00, OOPM 3120.00 + 260.00 = 3380.00
Wait, does B's deductible accumulator change? Since no deductible was applied (it was already met via family), B's deductible balance stays at 0.00. But does the family deductible accumulator change? It's already at 3000.00 (the max). So no change.
Actually, I need to think about whether B's deductible balance should be credited even when the family deductible is already met. In most systems, once the family deductible is met, no more deductible credits are accumulated for any member because the deductible phase is over. So B's deductible stays at 0.00.
Hmm, but actually - B's individual deductible balance might matter if we need to track it for some reason. But since the family deductible is already met, it doesn't matter for adjudication purposes.
Let me reconsider whether B's deductible should be credited. The claim is 1300.00 allowed. If the family deductible were NOT met, B would need to pay 1300.00 toward deductible (since B's balance is 0 and threshold is 1500). But since family deductible IS met, B pays coinsurance instead.
So B's deductible balance remains 0.00. The family deductible remains 3000.00.
Accumulators after Claim 2:
- A: deductible 3000.00, OOPM 3120.00
- B: deductible 0.00, OOPM 260.00
- Family: deductible 3000.00, OOPM 3380.00
---
**Claim 3 — 2026-06-14 — A (subscriber)**
- In-network follow-up procedure
- Billed: 3330.00, Allowed: 1800.00
- Network: In-network
For in-network services, the individual deductible threshold is 1500.00.
A's current deductible balance: 3000.00
Since 3000.00 >= 1500.00, A's individual deductible is met for in-network.
Also, family deductible is met (3000.00 >= 3000.00).
So deductible applied: 0.00
Coinsurance (in-network): 20% member / 80% plan
Allowed: 1800.00
Coinsurance amount: 1800.00 * 0.20 = 360.00
Plan paid: 1800.00 * 0.80 = 1440.00
Member responsibility: 360.00
Check: 360.00 + 1440.00 = 1800.00 ✓
Update accumulators:
- A: deductible 3000.00, OOPM 3120.00 + 360.00 = 3480.00
- B: deductible 0.00, OOPM 260.00
- Family: deductible 3000.00, OOPM 3380.00 + 360.00 = 3740.00
Accumulators after Claim 3:
- A: deductible 3000.00, OOPM 3480.00
- B: deductible 0.00, OOPM 260.00
- Family: deductible 3000.00, OOPM 3740.00
---
**Claim 4 — 2026-07-08 — A (subscriber)**
- Out-of-network diagnostic study
- Billed: 2960.00, Allowed: 1600.00
- Network: Out-of-network
For out-of-network services, the individual deductible threshold is 3000.00.
A's current deductible balance: 3000.00
Since 3000.00 >= 3000.00, A's individual deductible is met for out-of-network.
So deductible applied: 0.00
Coinsurance (out-of-network): 40% member / 60% plan
Allowed: 1600.00
Coinsurance amount: 1600.00 * 0.40 = 640.00
Plan paid: 1600.00 * 0.60 = 960.00
Member responsibility: 640.00
Check: 640.00 + 960.00 = 1600.00 ✓
Now let me check OOPM:
A's OOPM before Claim 4: 3480.00
A's individual OOPM for out-of-network: 12000.00
3480.00 + 640.00 = 4120.00 < 12000.00, so OOPM not reached.
Family OOPM: 3740.00 + 640.00 = 4380.00
Family OOPM (in-network): 12000.00
Not reached.
Update accumulators:
- A: deductible 3000.00, OOPM 3480.00 + 640.00 = 4120.00
- B: deductible 0.00, OOPM 260.00
- Family: deductible 3000.00, OOPM 3740.00 + 640.00 = 4380.00
---
**Claim 4 Components:**
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
**Ending Accumulators:**
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
Wait, let me reconsider the family deductible and how it interacts with out-of-network.
The plan says:
- Family (in-network): 3000.00
- "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
So there's a single member deductible balance, and a single family deductible balance (3000.00).
But wait - is there a separate out-of-network family deductible? The plan only lists:
- Family (in-network): 3000.00
There's no "Family (out-of-network)" listed. So I think the family deductible is 3000.00 regardless.
Let me re-examine Claim 1 more carefully.
Claim 1: A, out-of-network, allowed 2400.00
A's starting deductible balance: 900.00
Out-of-network individual threshold: 3000.00
Remaining: 3000.00 - 900.00 = 2100.00
Deductible applied: min(2400.00, 2100.00) = 2100.00
After deductible: 2400.00 - 2100.00 = 300.00
Coinsurance (OON): 40% of 300.00 = 120.00
Plan: 60% of 300.00 = 180.00
Member responsibility: 2100.00 + 120.00 = 2220.00
Plan paid: 180.00
A's deductible balance: 900.00 + 2100.00 = 3000.00
Family deductible: 900.00 + 2100.00 = 3000.00
Now, A's individual deductible balance is 3000.00, which meets the out-of-network threshold of 3000.00. ✓
Family deductible balance is 3000.00, which meets the family deductible of 3000.00. ✓
This all checks out.
Let me also reconsider whether B's deductible accumulator should increase when Claim 2 is processed.
Claim 2: B, in-network, allowed 1300.00
B's deductible balance: 0.00
Family deductible balance: 3000.00 (already met)
Since family deductible is met, B's deductible is satisfied. No deductible is applied.
Coinsurance (in-network): 20% of 1300.00 = 260.00
B's deductible balance stays at 0.00 (no deductible applied).
Family deductible stays at 3000.00.
This seems correct.
Actually, wait. Let me reconsider whether the family deductible really applies to B here. The embedded deductible structure says:
"an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
This means:
- If an individual meets their own deductible first, they get coinsurance
- If the family deductible is met first (through total family credits), then all members get coinsurance
Since family credits reached 3000.00 (from A's 900.00 starting + 2100.00 from Claim 1), the family deductible is satisfied. So B gets coinsurance without needing to meet B's own individual deductible.
This is correct.
Let me double-check all my math one more time.
**Claim 1:**
- Allowed: 2400.00
- A deductible start: 900.00
- OON threshold: 3000.00
- Deductible applied: 2100.00
- Remaining: 300.00
- Coinsurance (40%): 120.00
- Plan (60%): 180.00
- Member resp: 2220.00
- A deductible end: 3000.00
- A OOPM: 900.00 + 2220.00 = 3120.00
- Family deductible: 900.00 + 2100.00 = 3000.00
- Family OOPM: 900.00 + 2220.00 = 3120.00
**Claim 2:**
- Allowed: 1300.00
- B deductible start: 0.00
- Family deductible: 3000.00 (met)
- Deductible applied: 0.00
- Coinsurance (20%): 260.00
- Plan (80%): 1040.00
- Member resp: 260.00
- B deductible end: 0.00
- B OOPM: 0.00 + 260.00 = 260.00
- Family deductible: 3000.00
- Family OOPM: 3120.00 + 260.00 = 3380.00
**Claim 3:**
- Allowed: 1800.00
- A deductible start: 3000.00
- IN threshold: 1500.00 (met since 3000.00 >= 1500.00)
- Deductible applied: 0.00
- Coinsurance (20%): 360.00
- Plan (80%): 1440.00
- Member resp: 360.00
- A deductible end: 3000.00
- A OOPM: 3120.00 + 360.00 = 3480.00
- Family deductible: 3000.00
- Family OOPM: 3380.00 + 360.00 = 3740.00
**Claim 4:**
- Allowed: 1600.00
- A deductible start: 3000.00
- OON threshold: 3000.00 (met since 3000.00 >= 3000.00)
- Deductible applied: 0.00
- Coinsurance (40%): 640.00
- Plan (60%): 960.00
- Member resp: 640.00
- A deductible end: 3000.00
- A OOPM: 3480.00 + 640.00 = 4120.00
- Family deductible: 3000.00
- Family OOPM: 3740.00 + 640.00 = 4380.00
Everything checks out. Let me also verify member_responsibility + plan_paid = allowed for Claim 4:
640.00 + 960.00 = 1600.00 ✓
Now, about the OOPM for out-of-network:
- Individual OOPM (out-of-network): 12000.00
- A's OOPM: 4120.00 (well below 12000.00)
And family OOPM (in-network): 12000.00
- Family OOPM: 4380.00 (well below 12000.00)
So no OOPM cap is hit.
Let me also verify: does the out-of-network cost share count toward the in-network OOPM or the out-of-network OOPM?
The plan says:
- Individual (in-network) OOPM: 6000.00
- Individual (out-of-network) OOPM: 12000.00
For A's out-of-network claims, the cost share should count toward the out-of-network OOPM of 12000.00.
For A's in-network claims, the cost share should count toward the in-network OOPM of 6000.00.
Wait, but are there separate OOPM accumulators for in-network and out-of-network? The plan lists:
- Individual (in-network) OOPM: 6000.00
- Family (in-network) OOPM: 12000.00
- Individual (out-of-network) OOPM: 12000.00
This suggests there might be separate accumulators. But the task only asks for one OOPM per member and one for the family. Let me re-read the task.
The task asks for:
- ending_oopm_a
- ending_oopm_b
- ending_family_oopm
It doesn't distinguish between in-network and out-of-network OOPM.
Hmm, but how do I track this? If A has both in-network and out-of-network claims, do they share a single OOPM accumulator, or are there separate ones?
Looking at the plan document again:
- "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year."
It doesn't explicitly say they're separate accumulators. But it lists different thresholds for in-network and out-of-network.
In typical health plans, there are separate OOPM accumulators for in-network and out-of-network. But the task only asks for one OOPM value per member.
Let me think about this differently. Maybe there's a single OOPM accumulator, and the threshold it's measured against depends on the network status of the current service, similar to how the deductible works.
"In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
The plan explicitly says deductible credits accumulate to a single balance. It doesn't say the same about OOPM. But since the task only asks for one OOPM value, I'll assume there's a single OOPM accumulator.
Actually, wait. Let me re-read more carefully. The deductible section explicitly states: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
For OOPM, no such statement is made. But the task only asks for one ending_oopm value per member. So either:
1. There's a single OOPM accumulator (like the deductible)
2. The task is asking for a combined value
I think the most reasonable interpretation, given the task structure, is that there's a single OOPM accumulator that accumulates all cost share, and it's measured against different thresholds depending on network status. This is consistent with how the deductible works.
So A's OOPM accumulator is 4120.00, which includes both in-network and out-of-network cost share.
If A's next claim is in-network, we'd check against 6000.00.
If A's next claim is out-of-network, we'd check against 12000.00.
For the family OOPM, the plan lists:
- Family (in-network): 12000.00
There's no family (out-of-network) OOPM listed. So the family OOPM is 12000.00.
OK, I'll go with my calculations. Let me finalize:
**Claim 4 results:**
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
**Ending accumulators:**
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 7,898 tokens
Let me work through this step by step.
**Plan Details:**
- Individual deductible (in-network): 1500.00
- Family deductible (in-network): 3000.00
- Structure: EMBEDDED
- Out-of-network individual deductible: 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The threshold is measured against the out-of-network amount (3000.00) when the service is out-of-network.
- Individual OOPM (in-network): 6000.00
- Family OOPM (in-network): 12000.00
- Individual OOPM (out-of-network): 12000.00
- Coinsurance after deductible, in-network: 20% member / 80% plan
- Coinsurance after deductible, out-of-network: 40% member / 60% plan
- Copays do NOT credit the deductible. Copays always credit the OOPM.
**Starting Accumulators:**
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family total: deductible 900.00, OOPM 900.00
---
**Claim 1 — 2026-05-05 — A (subscriber)**
- Out-of-network specialist procedure
- Billed: 4440.00, Allowed: 2400.00
- Network: Out-of-network
For out-of-network services, the deductible threshold is 3000.00 (out-of-network individual deductible).
A's current deductible accumulator: 900.00
Remaining deductible for out-of-network: 3000.00 - 900.00 = 2100.00
Allowed amount: 2400.00
Deductible applied: min(2400.00, 2100.00) = 2100.00
Remaining after deductible: 2400.00 - 2100.00 = 300.00
Coinsurance (out-of-network, 40% member): 300.00 * 0.40 = 120.00
Plan paid: 300.00 * 0.60 = 180.00
Member responsibility: deductible_applied + coinsurance = 2100.00 + 120.00 = 2220.00
Plan paid: 180.00
Check: member_responsibility + plan_paid = 2220.00 + 180.00 = 2400.00 ✓
Update accumulators for A:
- A deductible: 900.00 + 2100.00 = 3000.00
- A OOPM: 900.00 + 2100.00 + 120.00 = 3120.00
Family:
- Family deductible: 900.00 + 2100.00 = 3000.00
- Family OOPM: 900.00 + 2100.00 + 120.00 = 3120.00
Now, A's individual deductible is 3000.00. Since this is out-of-network, the threshold is 3000.00, so A's individual deductible is satisfied.
Family deductible is 3000.00, which equals the family deductible threshold (3000.00 for in-network). Wait, the family deductible is 3000.00. So family deductible is also satisfied.
Wait, let me re-read: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So the deductible credits from both in-network and out-of-network go into one bucket. When the service is out-of-network, the threshold is 3000.00 (out-of-network individual). When the service is in-network, the threshold is 1500.00 (in-network individual).
Family deductible is 3000.00 (in-network). Is there a separate out-of-network family deductible? The plan document doesn't mention one explicitly. Let me re-read.
"Deductible
Individual (in-network) ................ 1500.00
Family (in-network) .................... 3000.00
Structure .............................. EMBEDDED
Out-of-network (individual) ............ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member
deductible balance. The amount above is the threshold that balance is measured
against when the service is out-of-network."
So there's no out-of-network family deductible listed. The family deductible is 3000.00. The individual out-of-network deductible is 3000.00.
For the family deductible, I think it's 3000.00 regardless. The family deductible credits would be the sum of all member deductible credits.
Let me re-think. The family deductible is 3000.00. A's deductible accumulator is now 3000.00. So the family deductible total is 3000.00, which meets the 3000.00 family deductible threshold. So family deductible is satisfied.
Actually wait - with embedded structure, "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
So A's individual deductible credits are 3000.00. For in-network services, A's individual threshold is 1500.00, so A has satisfied the in-network individual deductible. For out-of-network services, A's threshold is 3000.00, so A has also satisfied the out-of-network individual deductible.
Family deductible credits: 3000.00 (all from A). Family threshold: 3000.00. So family deductible is satisfied.
Now let me continue.
**Claim 2 — 2026-05-21 — B (spouse)**
- In-network outpatient imaging
- Billed: 2405.00, Allowed: 1300.00
- Network: In-network
B's current deductible accumulator: 0.00
For in-network, B's individual threshold: 1500.00
Remaining deductible: 1500.00 - 0.00 = 1500.00
But wait - family deductible is already satisfied (3000.00 credits). With embedded structure, the family deductible is satisfied once total family credits reach the family amount.
Hmm, but does family deductible satisfaction affect individual deductible? Let me re-read: "EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
I think "whichever comes first" means: either an individual satisfies their own individual deductible, OR the family deductible is satisfied (at which point all family members are treated as having met the deductible).
Actually, in typical embedded deductible structures, once the family deductible is met, all members get coinsurance regardless of whether they've met their individual deductible. Let me think about this more carefully.
Actually, re-reading: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
I think this means:
- Each person has an individual deductible that they can satisfy on their own.
- The family deductible is the total of all family members' credits.
- Once the family deductible is met, all members are considered to have met the deductible (even if their individual credits haven't reached the individual threshold).
So B's individual deductible credits are 0.00, but the family deductible is already met (3000.00). So B should get coinsurance on this claim.
Wait, but I need to think about this differently. In an embedded deductible:
- Individual deductible: 1500.00
- Family deductible: 3000.00
The way embedded works: each member's spending counts toward both their individual deductible and the family deductible. Once a member's individual spending reaches 1500.00, that member's deductible is met. Once the total family spending reaches 3000.00, ALL members' deductibles are considered met.
So since family deductible credits are 3000.00 (from A), the family deductible is met. Therefore B's deductible is considered met even though B has 0.00 in credits.
Let me proceed with that understanding.
Claim 2 — B:
- Allowed: 1300.00
- B's deductible is met (via family deductible being satisfied)
- Coinsurance (in-network, 20% member): 1300.00 * 0.20 = 260.00
- Plan paid: 1300.00 * 0.80 = 1040.00
- Member responsibility: 260.00
- Deductible applied: 0.00
Update accumulators for B:
- B deductible: 0.00 + 0.00 = 0.00 (no deductible applied)
- B OOPM: 0.00 + 260.00 = 260.00
Family:
- Family deductible: 3000.00 + 0.00 = 3000.00
- Family OOPM: 3120.00 + 260.00 = 3380.00
Wait, but does B's deductible accumulator change? If the family deductible is met, does B still need to accumulate? I think the deductible accumulator just tracks credits. Since no deductible was applied, B's deductible accumulator stays at 0.00.
Actually, I need to reconsider. Let me re-read the rules:
"A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
So: "a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
For B on Claim 2:
- B's individual remainder: 1500.00 - 0.00 = 1500.00
- Family remainder: 3000.00 - 3000.00 = 0.00
- Lesser of 1500.00 and 0.00 = 0.00
So B's deductible to satisfy is 0.00. That means the deductible is fully met for B. The deductible applied is 0.00.
Then coinsurance applies to the full 1300.00:
- Member coinsurance: 1300.00 * 0.20 = 260.00
- Plan: 1300.00 * 0.80 = 1040.00
Member responsibility: 0.00 + 260.00 = 260.00
Plan paid: 1040.00
Check: 260.00 + 1040.00 = 1300.00 ✓
Update accumulators:
- B deductible: 0.00 + 0.00 = 0.00
- B OOPM: 0.00 + 260.00 = 260.00
- Family deductible: 3000.00 + 0.00 = 3000.00
- Family OOPM: 3120.00 + 260.00 = 3380.00
**Claim 3 — 2026-06-14 — A (subscriber)**
- In-network follow-up procedure
- Billed: 3330.00, Allowed: 1800.00
- Network: In-network
A's current deductible accumulator: 3000.00
For in-network, A's individual threshold: 1500.00
A's individual remainder: max(1500.00 - 3000.00, 0) = 0.00
Family remainder: max(3000.00 - 3000.00, 0) = 0.00
Lesser: 0.00
So A's deductible is met. Deductible applied: 0.00.
Coinsurance (in-network, 20% member): 1800.00 * 0.20 = 360.00
Plan: 1800.00 * 0.80 = 1440.00
Member responsibility: 0.00 + 360.00 = 360.00
Plan paid: 1440.00
Check: 360.00 + 1440.00 = 1800.00 ✓
Update accumulators:
- A deductible: 3000.00 + 0.00 = 3000.00
- A OOPM: 3120.00 + 360.00 = 3480.00
- Family deductible: 3000.00 + 0.00 = 3000.00
- Family OOPM: 3380.00 + 360.00 = 3740.00
**Claim 4 — 2026-07-08 — A (subscriber)**
- Out-of-network diagnostic study
- Billed: 2960.00, Allowed: 1600.00
- Network: Out-of-network
A's current deductible accumulator: 3000.00
For out-of-network, A's individual threshold: 3000.00
A's individual remainder: max(3000.00 - 3000.00, 0) = 0.00
Family remainder: max(3000.00 - 3000.00, 0) = 0.00
Lesser: 0.00
So A's deductible is met. Deductible applied: 0.00.
Now, coinsurance (out-of-network, 40% member): 1600.00 * 0.40 = 640.00
Plan: 1600.00 * 0.60 = 960.00
But wait - I need to check A's OOPM.
A's current OOPM: 3480.00
For out-of-network, A's individual OOPM threshold: 12000.00
Remaining OOPM: 12000.00 - 3480.00 = 8520.00
The coinsurance amount (640.00) is less than the remaining OOPM (8520.00), so the full coinsurance applies.
Member responsibility: 0.00 + 640.00 = 640.00
Plan paid: 960.00
Check: 640.00 + 960.00 = 1600.00 ✓
Update accumulators:
- A deductible: 3000.00 + 0.00 = 3000.00
- A OOPM: 3480.00 + 640.00 = 4120.00
- Family deductible: 3000.00 + 0.00 = 3000.00
- Family OOPM: 3740.00 + 640.00 = 4380.00
Wait, I need to reconsider how OOPM works for out-of-network vs in-network.
The plan says:
- Individual OOPM (in-network): 6000.00
- Family OOPM (in-network): 12000.00
- Individual OOPM (out-of-network): 12000.00
It doesn't mention a family OOPM for out-of-network. Let me think about this.
Actually, for OOPM, there are separate thresholds:
- Individual in-network OOPM: 6000.00
- Individual out-of-network OOPM: 12000.00
- Family in-network OOPM: 12000.00
Does the OOPM accumulator also work like the deductible - single accumulator with different thresholds based on network status?
The plan document says for deductibles: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
It doesn't explicitly say the same for OOPM. But by analogy, I think OOPM credits also accumulate to a single balance, and the threshold depends on whether the current service is in-network or out-of-network.
Actually, wait. Let me think about this more carefully. In many plans, in-network and out-of-network OOPMs are separate accumulators. But this plan explicitly says deductible credits accumulate to a single balance. It doesn't say the same for OOPM.
Hmm, but the plan document doesn't specify separate OOPM accumulators either. Let me assume they also accumulate to a single balance with different thresholds, similar to the deductible.
Actually, looking at the plan document again:
"Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the
allowed amount for covered services for the remainder of the plan year."
It lists individual in-network (6000), family in-network (12000), and individual out-of-network (12000). There's no family out-of-network OOPM listed.
I think the most reasonable interpretation is:
- OOPM credits accumulate to a single balance (like the deductible)
- When the service is in-network, the individual threshold is 6000.00
- When the service is out-of-network, the individual threshold is 12000.00
- Family OOPM threshold is 12000.00
Let me re-check with this understanding.
For Claim 4 (out-of-network):
A's OOPM accumulator: 3480.00
A's individual out-of-network OOPM threshold: 12000.00
Remaining: 12000.00 - 3480.00 = 8520.00
Coinsurance: 640.00
640.00 < 8520.00, so full coinsurance applies.
Member responsibility: 640.00
Plan paid: 960.00
This seems correct.
Now let me also re-check the family OOPM. For Claim 4:
Family OOPM accumulator before Claim 4: 3740.00
Family OOPM threshold: 12000.00 (in-network family OOPM)
Wait, what's the family OOPM threshold for out-of-network? The plan doesn't list a family out-of-network OOPM. I'll assume it's the same 12000.00.
Actually, I think for family OOPM, the threshold is just 12000.00 regardless. Let me proceed with that.
Family OOPM after Claim 4: 3740.00 + 640.00 = 4380.00
Let me also re-examine whether the OOPM accumulator is truly single or separate for in-network and out-of-network.
Looking at the plan document, it says for deductibles: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
It does NOT say this for OOPM. This could mean OOPM accumulators are separate for in-network and out-of-network.
If OOPM accumulators are separate:
- A's in-network OOPM accumulator: Let me trace through
- Start: 900.00 (given as starting OOPM)
Hmm, but the starting accumulator just says "out-of-pocket 900.00" without specifying in-network or out-of-network. This suggests it's a single accumulator.
I'll go with single OOPM accumulator, similar to deductible, with different thresholds based on network status.
Let me re-trace everything with this assumption:
**Starting Accumulators:**
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family: deductible 900.00, OOPM 900.00
**Claim 1 — A — Out-of-network, Allowed 2400.00**
A's deductible remainder (out-of-network threshold 3000.00): 3000.00 - 900.00 = 2100.00
Family deductible remainder: 3000.00 - 900.00 = 2100.00
Lesser: 2100.00
Deductible applied: min(2400.00, 2100.00) = 2100.00
Remaining after deductible: 2400.00 - 2100.00 = 300.00
Coinsurance (out-of-network, 40%): 300.00 * 0.40 = 120.00
Plan coinsurance: 300.00 * 0.60 = 180.00
Member responsibility: 2100.00 + 120.00 = 2220.00
Plan paid: 180.00
Check: 2220.00 + 180.00 = 2400.00 ✓
Update accumulators:
- A deductible: 900.00 + 2100.00 = 3000.00
- A OOPM: 900.00 + 2100.00 + 120.00 = 3120.00
- B deductible: 0.00
- B OOPM: 0.00
- Family deductible: 900.00 + 2100.00 = 3000.00
- Family OOPM: 900.00 + 2100.00 + 120.00 = 3120.00
**Claim 2 — B — In-network, Allowed 1300.00**
B's deductible remainder (in-network threshold 1500.00): 1500.00 - 0.00 = 1500.00
Family deductible remainder: 3000.00 - 3000.00 = 0.00
Lesser: 0.00
Deductible applied: 0.00
Remaining after deductible: 1300.00
Coinsurance (in-network, 20%): 1300.00 * 0.20 = 260.00
Plan coinsurance: 1300.00 * 0.80 = 1040.00
Member responsibility: 0.00 + 260.00 = 260.00
Plan paid: 1040.00
Check: 260.00 + 1040.00 = 1300.00 ✓
Update accumulators:
- A deductible: 3000.00
- A OOPM: 3120.00
- B deductible: 0.00 + 0.00 = 0.00
- B OOPM: 0.00 + 260.00 = 260.00
- Family deductible: 3000.00 + 0.00 = 3000.00
- Family OOPM: 3120.00 + 260.00 = 3380.00
**Claim 3 — A — In-network, Allowed 1800.00**
A's deductible remainder (in-network threshold 1500.00): 1500.00 - 3000.00 = 0.00 (already exceeded)
Family deductible remainder: 3000.00 - 3000.00 = 0.00
Lesser: 0.00
Deductible applied: 0.00
Remaining after deductible: 1800.00
Coinsurance (in-network, 20%): 1800.00 * 0.20 = 360.00
Plan coinsurance: 1800.00 * 0.80 = 1440.00
But wait, check OOPM:
A's OOPM: 3120.00
A's in-network OOPM threshold: 6000.00
Remaining: 6000.00 - 3120.00 = 2880.00
Coinsurance 360.00 < 2880.00, so full coinsurance applies.
Member responsibility: 0.00 + 360.00 = 360.00
Plan paid: 1440.00
Check: 360.00 + 1440.00 = 1800.00 ✓
Update accumulators:
- A deductible: 3000.00
- A OOPM: 3120.00 + 360.00 = 3480.00
- B deductible: 0.00
- B OOPM: 260.00
- Family deductible: 3000.00
- Family OOPM: 3380.00 + 360.00 = 3740.00
**Claim 4 — A — Out-of-network, Allowed 1600.00**
A's deductible remainder (out-of-network threshold 3000.00): 3000.00 - 3000.00 = 0.00
Family deductible remainder: 3000.00 - 3000.00 = 0.00
Lesser: 0.00
Deductible applied: 0.00
Remaining after deductible: 1600.00
Coinsurance (out-of-network, 40%): 1600.00 * 0.40 = 640.00
Plan coinsurance: 1600.00 * 0.60 = 960.00
Check OOPM:
A's OOPM: 3480.00
A's out-of-network OOPM threshold: 12000.00
Remaining: 12000.00 - 3480.00 = 8520.00
Coinsurance 640.00 < 8520.00, so full coinsurance applies.
Member responsibility: 0.00 + 640.00 = 640.00
Plan paid: 960.00
Check: 640.00 + 960.00 = 1600.00 ✓
Update accumulators:
- A deductible: 3000.00
- A OOPM: 3480.00 + 640.00 = 4120.00
- B deductible: 0.00
- B OOPM: 260.00
- Family deductible: 3000.00
- Family OOPM: 3740.00 + 640.00 = 4380.00
**Summary for Claim 4:**
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
**Ending Accumulators:**
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
Let me double-check everything one more time.
Claim 1: A, out-of-network, allowed 2400
- A deductible was 900, out-of-network threshold is 3000, remainder is 2100
- Family deductible was 900, threshold 3000, remainder is 2100
- Lesser is 2100
- Deductible applied: 2100
- Remaining: 300
- Coinsurance (40%): 120
- Plan (60%): 180
- Member responsibility: 2100 + 120 = 2220
- A deductible: 900 + 2100 = 3000
- A OOPM: 900 + 2100 + 120 = 3120
- Family deductible: 900 + 2100 = 3000
- Family OOPM: 900 + 2100 + 120 = 3120
Claim 2: B, in-network, allowed 1300
- B deductible was 0, in-network threshold is 1500, remainder is 1500
- Family deductible was 3000, threshold 3000, remainder is 0
- Lesser is 0
- Deductible applied: 0
- Remaining: 1300
- Coinsurance (20%): 260
- Plan (80%): 1040
- Member responsibility: 260
- B deductible: 0
- B OOPM: 0 + 260 = 260
- Family deductible: 3000
- Family OOPM: 3120 + 260 = 3380
Claim 3: A, in-network, allowed 1800
- A deductible was 3000, in-network threshold is 1500, remainder is 0
- Family deductible was 3000, threshold 3000, remainder is 0
- Lesser is 0
- Deductible applied: 0
- Remaining: 1800
- Coinsurance (20%): 360
- Plan (80%): 1440
- A OOPM check: 3120, in-network threshold 6000, remainder 2880. 360 < 2880. OK.
- Member responsibility: 360
- A deductible: 3000
- A OOPM: 3120 + 360 = 3480
- Family deductible: 3000
- Family OOPM: 3380 + 360 = 3740
Claim 4: A, out-of-network, allowed 1600
- A deductible was 3000, out-of-network threshold is 3000, remainder is 0
- Family deductible was 3000, threshold 3000, remainder is 0
- Lesser is 0
- Deductible applied: 0
- Remaining: 1600
- Coinsurance (40%): 640
- Plan (60%): 960
- A OOPM check: 3480, out-of-network threshold 12000, remainder 8520. 640 < 8520. OK.
json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 11,446 tokens
Let me work through this step by step.
**Plan Document Summary:**
- Individual deductible (in-network): 1500.00
- Family deductible (in-network): 3000.00
- Structure: EMBEDDED
- Out-of-network deductible (individual): 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The threshold is measured against the out-of-network amount when the service is out-of-network.
Wait, let me re-read: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So there's one deductible accumulator per member. When processing an in-network claim, the threshold is 1500.00. When processing an out-of-network claim, the threshold is 3000.00.
- OOPM Individual (in-network): 6000.00
- OOPM Family (in-network): 12000.00
- OOPM Individual (out-of-network): 12000.00
Wait, is there a family out-of-network OOPM? The plan doesn't list one explicitly. Let me re-read.
"Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00"
No family out-of-network OOPM listed. I'll need to think about how to handle this.
Coinsurance:
- In-network: 20% member / 80% plan
- Out-of-network: 40% member / 60% plan
Copays don't credit deductible, but always credit OOPM.
**Starting Accumulators:**
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family: deductible 900.00, OOPM 900.00
---
**Claim 1 — 2026-05-05 — A (subscriber)**
- Out-of-network specialist procedure
- Billed: 4440.00, Allowed: 2400.00
- Network: Out-of-network
For out-of-network, the deductible threshold is 3000.00.
A's deductible accumulator is 900.00.
Remaining deductible for out-of-network: 3000.00 - 900.00 = 2100.00
Allowed amount: 2400.00
Deductible applied: min(2400.00, 2100.00) = 2100.00
Remaining after deductible: 2400.00 - 2100.00 = 300.00
Coinsurance (out-of-network): 40% member / 60% plan
Coinsurance amount (member): 300.00 * 0.40 = 120.00
Plan coinsurance: 300.00 * 0.60 = 180.00
Member responsibility: 2100.00 (deductible) + 120.00 (coinsurance) = 2220.00
Plan paid: 180.00
Check: member_responsibility + plan_paid = 2220.00 + 180.00 = 2400.00 = allowed amount. ✓
Now, does A hit the OOPM?
For out-of-network, individual OOPM is 12000.00.
A's OOPM accumulator was 900.00. Now add 2220.00 = 3120.00. Not at 12000.00.
Wait, but I also need to think about the family OOPM. The family OOPM for in-network is 12000.00. There's no family out-of-network OOPM listed. Let me think about this...
Actually, let me re-read: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year."
There are individual OOPMs for in-network (6000) and out-of-network (12000), and a family OOPM for in-network (12000). No family out-of-network OOPM is listed.
I think for out-of-network claims, the individual OOPM threshold is 12000.00. For in-network claims, the individual OOPM threshold is 6000.00. The family OOPM of 12000.00 applies to in-network.
Actually, wait. The OOPM accumulator is also a single balance, similar to the deductible? Let me re-read...
The plan says: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
It doesn't say the same about OOPM. But the structure seems similar. Let me assume OOPM credits also accumulate to a single balance, and the threshold depends on the network status of the current claim.
Actually, let me think more carefully. The plan says:
- Individual OOPM (in-network): 6000.00
- Family OOPM (in-network): 12000.00
- Individual OOPM (out-of-network): 12000.00
For the OOPM, when a claim is in-network, the threshold is 6000 (individual) or 12000 (family). When out-of-network, the individual threshold is 12000. No family out-of-network is listed.
I think the OOPM accumulator works similarly to the deductible - single balance, threshold depends on network status. Let me proceed with that assumption.
Actually, wait. I need to reconsider. Let me think about whether in-network and out-of-network cost sharing credits go to the same OOPM accumulator.
The plan explicitly says deductible credits accumulate to a single balance. It doesn't say the same for OOPM. In many real plans, in-network and out-of-network OOPM accumulators are separate. But the plan explicitly says deductible is single, so maybe OOPM is also single?
Hmm, the plan doesn't explicitly say OOPM is single. But it also doesn't say they're separate. Given the deductible is explicitly single, and the plan doesn't say OOPM is separate, I'll assume OOPM is also a single accumulator with thresholds that depend on network status.
Actually, let me reconsider. In many plans, in-network and out-of-network OOPMs are separate accumulators. The plan explicitly says deductible credits accumulate to a SINGLE balance. The absence of such language for OOPM might mean they're separate. But then, the starting accumulators only show one OOPM value per member (900.00 for A, 0.00 for B), not separate in-network and out-of-network OOPM values. This suggests a single OOPM accumulator.
I'll go with a single OOPM accumulator, with thresholds depending on network status:
- In-network: individual 6000, family 12000
- Out-of-network: individual 12000
Let me proceed.
**Claim 1 — A — Out-of-network**
- Allowed: 2400.00
- A's deductible accumulator: 900.00 → threshold for OON is 3000.00
- Deductible remaining: 3000.00 - 900.00 = 2100.00
- Deductible applied: min(2400.00, 2100.00) = 2100.00
- Remaining after deductible: 2400.00 - 2100.00 = 300.00
- Coinsurance (OON 40%): 300.00 * 0.40 = 120.00
- Member responsibility: 2100.00 + 120.00 = 2220.00
- Plan paid: 300.00 * 0.60 = 180.00
- Copay: 0.00
Update accumulators:
- A deductible: 900.00 + 2100.00 = 3000.00
- A OOPM: 900.00 + 2220.00 = 3120.00
- Family deductible: 900.00 + 2100.00 = 3000.00
- Family OOPM: 900.00 + 2220.00 = 3120.00
Check: Does A hit OON individual deductible? 3000.00 = 3000.00. Yes, satisfied.
Does family deductible hit? Family is 3000.00. The family deductible threshold is 3000.00 (in-network). Wait, what's the family deductible threshold for out-of-network? The plan doesn't list a family out-of-network deductible.
Hmm, let me re-read:
"Deductible
Individual (in-network) ................ 1500.00
Family (in-network) .................... 3000.00
Structure .............................. EMBEDDED
Out-of-network (individual) ............ 3000.00"
So there's only an individual out-of-network deductible (3000.00), no family out-of-network deductible.
The family deductible is 3000.00 (in-network). But since deductible credits accumulate to a single balance, and the family deductible is 3000.00...
Actually, I think the family deductible is always measured at 3000.00 regardless of network status. The individual threshold changes based on network (1500 for IN, 3000 for OON), but the family threshold is 3000.
Let me re-read: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
"The amount above" refers to the out-of-network individual deductible of 3000.00. So the individual member's balance is measured against 3000 when the service is out-of-network.
For the family deductible, it's 3000.00. This is the total family credits needed.
So after Claim 1:
- A's deductible balance: 3000.00 (satisfies OON individual deductible of 3000, and also IN individual deductible of 1500)
- Family deductible balance: 3000.00 (satisfies family deductible of 3000)
Now for OOPM:
- A's OOPM balance: 3120.00
- OON individual OOPM threshold: 12000.00 → not reached
- Family OOPM balance: 3120.00
- Family OOPM threshold: 12000.00 (in-network) → not reached
Wait, but is A's deductible satisfied for future in-network claims too? Yes, because the balance is 3000.00 which exceeds the in-network individual threshold of 1500.00.
**Claim 2 — 2026-05-21 — B (spouse)**
- In-network outpatient imaging
- Billed: 2405.00, Allowed: 1300.00
- Network: In-network
B's deductible accumulator: 0.00
Threshold for IN: 1500.00
Deductible remaining: 1500.00 - 0.00 = 1500.00
But wait, the family deductible is already satisfied (3000.00). Under embedded structure: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
So the family deductible is already met. Does that mean B's deductible is waived?
Under embedded structure, the family deductible being satisfied means... hmm, let me think about this.
"EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
In an embedded deductible structure:
- Each individual has their own deductible (1500 IN)
- The family has a family deductible (3000)
- An individual's deductible can be satisfied on its own (by that individual's spending)
- The family deductible is satisfied when total family spending reaches 3000
But what happens when the family deductible is satisfied but an individual's deductible is not?
In typical embedded deductible plans, once the family deductible is met, all family members' deductibles are considered satisfied, even if their individual deductible hasn't been met. This is because the family deductible acts as a cap on the total deductible the family has to pay.
Wait, actually that's the aggregate deductible behavior. Let me re-read.
"EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
In a true embedded deductible:
- Each person has an individual deductible
- The family has a family deductible
- Once an individual meets their individual deductible, coinsurance starts for that person
- Once the family meets the family deductible, all members who haven't met their individual deductible are considered to have met it
Actually, I think in an embedded structure, the family deductible is the maximum total deductible the family pays. Once family spending reaches the family deductible, no more deductible is collected from any family member.
Let me think about this differently. The rule says "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
So: member's deductible applied = min(individual remaining deductible, family remaining deductible)
After Claim 1:
- Family deductible balance: 3000.00, family threshold: 3000.00
- Family remaining deductible: 3000.00 - 3000.00 = 0.00
For Claim 2 (B, in-network):
- B's individual remaining deductible: 1500.00 - 0.00 = 1500.00
- Family remaining deductible: 0.00
- Deductible applied: min(1500.00, 0.00) = 0.00
So B's deductible is 0.00 because the family deductible is already satisfied!
This makes sense with embedded deductibles.
Allowed: 1300.00
Deductible applied: 0.00
Remaining after deductible: 1300.00
Coinsurance (IN 20%): 1300.00 * 0.20 = 260.00
Plan coinsurance: 1300.00 * 0.80 = 1040.00
Member responsibility: 0.00 + 260.00 = 260.00
Plan paid: 1040.00
Check: 260.00 + 1040.00 = 1300.00 ✓
Update accumulators:
- B deductible: 0.00 + 0.00 = 0.00
- B OOPM: 0.00 + 260.00 = 260.00
- Family deductible: 3000.00 + 0.00 = 3000.00
- Family OOPM: 3120.00 + 260.00 = 3380.00
**Claim 3 — 2026-06-14 — A (subscriber)**
- In-network follow-up procedure
- Billed: 3330.00, Allowed: 1800.00
- Network: In-network
A's deductible accumulator: 3000.00
Threshold for IN: 1500.00
A's individual remaining: 1500.00 - 3000.00 = already satisfied (negative, so 0)
Family remaining: 3000.00 - 3000.00 = 0.00
Deductible applied: min(0, 0) = 0.00
Allowed: 1800.00
Deductible applied: 0.00
Remaining: 1800.00
Coinsurance (IN 20%): 1800.00 * 0.20 = 360.00
Plan coinsurance: 1800.00 * 0.80 = 1440.00
Member responsibility: 360.00
Plan paid: 1440.00
Check: 360.00 + 1440.00 = 1800.00 ✓
Now check OOPM for A:
A's OOPM before: 3120.00
Add member responsibility: 3120.00 + 360.00 = 3480.00
IN individual OOPM threshold: 6000.00 → not reached
Update accumulators:
- A deductible: 3000.00 (no change)
- A OOPM: 3120.00 + 360.00 = 3480.00
- Family deductible: 3000.00 (no change)
- Family OOPM: 3380.00 + 360.00 = 3740.00
**Claim 4 — 2026-07-08 — A (subscriber)**
- Out-of-network diagnostic study
- Billed: 2960.00, Allowed: 1600.00
- Network: Out-of-network
A's deductible accumulator: 3000.00
Threshold for OON: 3000.00
A's individual remaining: 3000.00 - 3000.00 = 0.00
Family remaining: 3000.00 - 3000.00 = 0.00
Deductible applied: 0.00
Allowed: 1600.00
Deductible applied: 0.00
Remaining: 1600.00
Coinsurance (OON 40%): 1600.00 * 0.40 = 640.00
Plan coinsurance: 1600.00 * 0.60 = 960.00
Member responsibility: 640.00
Plan paid: 960.00
Check: 640.00 + 960.00 = 1600.00 ✓
Now check OOPM for A:
A's OOPM before: 3480.00
Add member responsibility: 3480.00 + 640.00 = 4120.00
For out-of-network claim, what's the OOPM threshold? Individual OON OOPM is 12000.00.
4120.00 < 12000.00, so not reached.
But wait, do I also need to check against the in-network OOPM? Since the OOPM is a single accumulator...
Actually, let me reconsider the OOPM structure. The plan lists:
- Individual (in-network): 6000.00
- Family (in-network): 12000.00
- Individual (out-of-network): 12000.00
If OOPM credits accumulate to a single balance (like the deductible), then when processing an OON claim, the threshold is 12000 (individual OON). When processing an IN claim, the threshold is 6000 (individual IN).
But wait, should in-network spending count toward the out-of-network OOPM and vice versa? In many plans, they're separate accumulators. The plan explicitly says deductible credits accumulate to a single balance. It does NOT say the same for OOPM.
Hmm, but the starting accumulators only show one OOPM value per member. If they were separate, we'd expect to see IN-OOPM and OON-OOPM separately.
Let me re-read the starting accumulators:
"A (subscriber) deductible 900.00 out-of-pocket 900.00"
Just one out-of-pocket value. This suggests a single OOPM accumulator.
OK so with a single OOPM accumulator, when processing an OON claim, the individual threshold is 12000.00. A's balance is 4120.00, so not reached.
But wait, I need to also consider: does the family OOPM apply here? The family OOPM is listed as 12000.00 (in-network). There's no family OON OOPM listed.
For the family OOPM on an OON claim: since no family OON OOPM is listed, maybe the family OOPM doesn't apply to OON claims? Or maybe the family OOPM of 12000 applies regardless?
Actually, looking at the task rules: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
This rule is about deductibles. For OOPM, the plan says: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year."
Let me think about the family OOPM. The plan says family OOPM (in-network) is 12000.00. The current family OOPM is 3740.00. The family remaining for in-network would be 12000.00 - 3740.00 = 8260.00.
For Claim 4 (OON), does the family OOPM matter? I think the family OOPM only applies to in-network services, since only an in-network family OOPM is listed.
So for Claim 4, I only check A's individual OON OOPM of 12000.00. A's balance is 4120.00, not reached.
Let me also reconsider whether the family OOPM should be checked for IN claims. For Claim 2 (B, IN), B's individual IN OOPM is 6000.00, B's balance is 260.00. Family OOPM is 12000.00, family balance is 3380.00. Neither is reached.
For Claim 3 (A, IN), A's individual IN OOPM is 6000.00, A's balance is 3480.00. Not reached.
OK, so for Claim 4:
- Deductible applied: 0.00
- Coinsurance amount: 640.00
- Copay: 0.00
- Member responsibility: 640.00
- Plan paid: 960.00
Update accumulators after Claim 4:
- A deductible: 3000.00
- A OOPM: 3480.00 + 640.00 = 4120.00
- B deductible: 0.00
- B OOPM: 260.00
- Family deductible: 3000.00
- Family OOPM: 3740.00 + 640.00 = 4380.00
Wait, let me reconsider the OOPM accumulator structure more carefully.
The plan explicitly says about deductibles: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
It does NOT say this about OOPM. In the absence of such a statement, and given that the plan lists separate OOPM thresholds for in-network and out-of-network, maybe OOPM accumulators ARE separate for IN and OON?
But the starting accumulators only show one OOPM value. If they were separate, we'd need to know the split.
I think the most reasonable interpretation given the data is that OOPM is also a single accumulator, similar to the deductible. The threshold changes based on network status of the current claim.
Let me proceed with that.
Actually, wait. Let me reconsider. Maybe in-network and out-of-network OOPM credits do NOT accumulate together. Maybe the starting 900.00 for A is all in-network (since the problem doesn't specify). And out-of-network spending goes to a separate OON OOPM accumulator.
If that's the case:
After Claim 1 (A, OON):
- A IN-OOPM: 900.00 (unchanged)
- A OON-OOPM: 2220.00 (new)
- But the starting accumulator just says "out-of-pocket 900.00"...
This is getting complicated. Let me just go with single OOPM accumulator since that's what the starting data implies.
Actually, wait. Let me reconsider once more. Maybe the 900.00 starting OOPM for A includes both IN and OON spending. The problem just gives us one number. So it's a single accumulator.
Let me go with single OOPM accumulator. Threshold depends on network status:
- IN claim: individual threshold 6000, family threshold 12000
- OON claim: individual threshold 12000, family threshold... not specified for OON
For family OOPM on OON claims, since no family OON OOPM is listed, I'll assume the family OOPM doesn't cap OON spending (only the individual OON OOPM of 12000 applies).
Actually, let me reconsider whether family OOPM applies to OON claims at all. The plan says:
"Family (in-network) .................... 12000.00"
This specifically says "in-network." So the family OOPM of 12000 only applies to in-network services. For OON services, only the individual OON OOPM of 12000 applies.
But does OON spending count toward the family IN OOPM? In a single-accumulator model, yes. In a separate-accumulator model, no.
Given the single-accumulator model (which the starting data implies), OON spending does count toward the family IN OOPM. So family OOPM goes up with all spending.
Let me just proceed with my calculations.
Let me also reconsider Claim 2. For Claim 2, B is in-network.
Actually wait - I need to reconsider the OOPM for B. For in-network claims, the individual OOPM threshold is 6000.00. But should I also check the family OOPM?
Under embedded structure for OOPM, similar to deductible: a member's OOPM is satisfied by the lesser of their individual OOPM remainder and the family OOPM remainder.
Actually, the task rules say: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
This is specifically about deductibles. For OOPM, the plan says: "Once a member reaches the out-of-pocket maximum the plan pays 100%..."
I think the OOPM works similarly - if the family OOPM is reached, all members are considered to have reached their OOPM. Let me apply this logic.
For Claim 4 (A, OON):
- A's indijson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100GLM-5.3 · Z.ai27.8s · 5,039 out | 10.4s · 936 out | 35.0s · 6,553 out
Reasoning · 4,741 tokens
We need to adjudicate four claims in order, tracking deductibles and OOPM for members A and B and family.
Plan: Bluebonnet PPO 1500.
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00
- Structure: EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
- Out-of-network individual deductible: 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
Hmm, this is tricky. Let's parse: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So the member has a single deductible balance (credits accumulate from both in-network and out-of-network services). When a service is in-network, the threshold is the individual in-network deductible (1500). When a service is out-of-network, the threshold is 3000 (the OON individual deductible).
So for A: starting deductible credit 900.00. OOPM 900.00.
Family deductible total: 900.00 (A 900, B 0). Family OOPM 900.
OOPM: Individual in-network 6000; family in-network 12000; individual out-of-network 12000. Hmm, so similar structure? The plan document only says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." There's a family OOPM of 12000 in-network. There's no family OOPM out-of-network listed. Individual OON OOPM is 12000.
Question: Does OOPM have a single combined balance similar to deductible? The plan doesn't explicitly say. It says "Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000". Hmm. Presumably similar embedded structure: the individual OOPM is 6000 in-network; if service is OON, threshold measured against 12000. But does OON cost share credit a single member OOPM balance? The plan says copays always credit the OOPM. The deductible section says in-network and out-of-network deductible credits accumulate to a single member deductible balance. For OOPM, no such statement. But typically the accumulator would be single. Let me think about what the harness intends.
Let's just adjudicate.
Claim 1 — 2026-05-05 — A, OON specialist procedure. Billed 4440, Allowed 2400. No copay applies (specialist OON procedure — the copays listed: primary care office visit 30, specialist office visit 60, urgent care 75, ER 400, generic retail 15. The copays presumably apply in-network? The plan document lists "Member cost share": coinsurance after deductible in-network 20%/80%, OON 40%/60%; copays for PCP, specialist, urgent care, ER, pharmacy. It doesn't say copays apply only in-network. Hmm. For OON services, typically copays don't apply; OON uses deductible + coinsurance. The task says "Out-of-network specialist procedure". Given the cost share section lists coinsurance OON 40%/60%, I think OON services are subject to deductible and coinsurance at 40%, not copays. The copays are presumably for in-network services. Actually the plan document doesn't explicitly restrict copays to in-network. But the structure "Coinsurance after deductible, out-of-network 40% member / 60% plan" suggests OON claims are handled via deductible + coinsurance. I'll go with that: OON claims: deductible + 40% coinsurance; copays not applicable (copay_amount 0 for OON claims). Also, the OON threshold for deductible is 3000 (individual OON deductible).
Wait, but does the OON deductible threshold of 3000 apply as "the threshold that balance is measured against when the service is out-of-network"? Yes. So A's single deductible balance is 900.00. For an OON service, the threshold is 3000. So A must satisfy up to 3000 of deductible credit before coinsurance begins (for OON services). Hmm, but embedded: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." The family deductible is 3000 (in-network). Is there a family OON deductible? Not listed. Hmm.
This is getting complex. Let's think carefully about the intended adjudication.
Claim 1: A, OON, allowed 2400.
- A's deductible balance: 900 (credit). Threshold for OON service: 3000 (individual OON deductible). Remainder for A: 3000 - 900 = 2100.
- Family deductible: 900 total; family threshold 3000 (in-network family). Family remainder: 2100.
- Under embedded structure: "a member's deductible is satisfied by the lesser of their individual remainder and the family remainder" (from the task family rules). For OON, individual remainder = 3000 - 900 = 2100; family remainder = 3000 - 900 = 2100. Lesser = 2100.
- Claim allowed 2400. Deductible applied: min(2400, 2100) = 2100. So A pays 2100 toward deductible. Remaining 300 of allowed: coinsurance OON 40% member = 120 member, plan 60% = 180.
- Member responsibility: 2100 + 120 = 2220. Plan paid: 180.
- Check: 2220 + 180 = 2400. ✓.
Update accumulators: A deductible balance: 900 + 2100 = 3000. A OOPM: 900 + 2220 = 3120. Family deductible: 900 + 2100 = 3000. Family OOPM: 900 + 2220 = 3120.
Wait — but does the OON deductible credit threshold interplay cause issues? A's balance is now 3000. For in-network services, threshold is 1500 — already satisfied. For OON services, threshold 3000 — now satisfied. OK.
Hmm, but wait: is it right that the whole 2100 counts toward the deductible, given the family deductible? Family deductible 3000 in-network. Family total after claim 1 = 3000, which satisfies the family deductible. That's fine.
But hold on — should the deductible applied be capped at the individual in-network deductible of 1500 because... no. The service is OON; the threshold measured is the OON individual deductible 3000. The embedded rule: individual satisfies individual deductible on their own; family deductible satisfied once total family credits reach family amount, whichever comes first. For an OON service, the relevant individual threshold is 3000.
Hmm, but there's ambiguity: maybe the intended interpretation is simpler: The single member deductible balance; in-network threshold 1500; OON threshold 3000. Family threshold 3000. Let's continue.
Claim 2: B, in-network outpatient imaging. Allowed 1300. B deductible balance 0, OOPM 0. Family deductible now 3000 (satisfied!). Family OOPM 3120.
Interesting: family deductible is satisfied after claim 1 (3000 = family deductible). Under embedded structure, once the family deductible is satisfied, no more deductible applies for any member? "the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." So after family deductible is met, subsequent claims don't have deductible. Also B's individual deductible (1500) — B has 0 credit, but family deductible is satisfied, so B's services are not subject to deductible. Under embedded, "a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Family remainder = 3000 - 3000 = 0. So lesser = 0. So B's deductible applied = 0.
Claim 2: B, in-network imaging, allowed 1300. Deductible applied: 0 (family deductible already satisfied). Coinsurance 20% member: 260. Plan 80%: 1040. Member responsibility: 260. Plan paid: 1040. 260 + 1040 = 1300 ✓.
Copay? Outpatient imaging — no copay listed for imaging; it's subject to deductible/coinsurance. Copay amount 0.
Update: B deductible balance stays 0 (no deductible applied). Actually, should B's deductible accumulator remain 0? Yes, since deductible applied was 0. B OOPM: 0 + 260 = 260. Family deductible stays 3000. Family OOPM: 3120 + 260 = 3380.
Claim 3: A, in-network follow-up procedure, allowed 1800. A deductible balance 3000, which exceeds in-network threshold 1500 — satisfied. Family deductible 3000 — satisfied. So deductible applied 0. Coinsurance in-network 20% member: 360. Plan: 1440. Member responsibility: 360. Total 1800 ✓.
A OOPM: 3120 + 360 = 3480. Family OOPM: 3380 + 360 = 3740.
Claim 4: A, OON diagnostic study, allowed 1600. A deductible balance 3000, OON threshold 3000 — satisfied exactly. Family deductible satisfied. So deductible applied 0. Coinsurance OON 40% member: 640. Plan 60%: 960. Member responsibility: 640. Plan paid: 960. 640+960 = 1600 ✓.
A OOPM: 3480 + 640 = 4120. Family OOPM: 3740 + 640 = 4380.
Check OOPM thresholds: A individual in-network OOPM 6000; OON individual OOPM 12000. Hmm — does A's OOPM balance of 4120 get measured against 12000 for OON services? Either way, 4120 < 6000 < 12000, so no OOPM reached. Family OOPM 4380 < 12000. Fine.
Now, the question asks: "Report the components for Claim 4, and the ending accumulators for every member and for the family."
Required keys:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00 (for claim 4)
- copay_amount: 0.00
- coinsurance_amount: 640.00
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
Let me double-check claim 1 logic more carefully, since it drives everything.
A's deductible balance at start: 900. The service is OON. "Out-of-network (individual) 3000.00" and "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So A's balance 900 measured against threshold 3000 for this OON service. Remaining deductible for A on this claim: 3000 - 900 = 2100.
Family embedded: family deductible 3000 (in-network). Family credits 900. Family remainder 2100. Lesser of individual remainder (2100) and family remainder (2100) = 2100. Deductible applied on claim 1: min(2100, allowed 2400) = 2100.
Coinsurance on remaining 300 at 40% = 120. Member responsibility 2220. Plan 180.
After claim 1: A deductible balance 3000; family deductible total 3000.
Now here's a subtle question: The family deductible of 3000 is described as "Family (in-network)". Is the family deductible satisfied by OON credits? The plan says in-network and OON credits accumulate to a single member deductible balance. The family total is the sum of member balances presumably. The family deductible threshold 3000 in-network. There's no family OON deductible. I think the family deductible total accumulates all credits (both networks) against the 3000 threshold. So after claim 1, family deductible = 3000 = satisfied.
Then claims 2-4 have no deductible. That seems to be the intended design: claim 1's big OON claim blows through both A's OON individual deductible and the family deductible simultaneously (both 3000). Then everything after is coinsurance only. That yields a clean answer.
But wait — let me reconsider whether the intended reading is that A's deductible applied on claim 1 should be capped at 2100 or something else. Let's consider the alternative: maybe the harness intends the embedded individual deductible for OON to also be 3000 and family 3000, and A's remainder = 2100, family remainder = 2100. Deductible applied 2100, coinsurance 40% of 300 = 120. Member resp 2220, plan 180. That's what I have.
Alternative interpretation: Maybe the OON deductible threshold only applies... hmm, another thought: maybe the plan intends that the member's single deductible balance is measured against the individual in-network deductible (1500) for in-network services and the OON deductible (3000) for OON services. With A at 900, OON claim: remainder 2100. Yes.
But another possible interpretation: The deductible credit accumulates in a single balance, and the threshold is 1500 in-network / 3000 OON. For claim 1, A has 900 credit; needs 2100 more to reach OON threshold. Family remainder: family deductible 3000 - 900 = 2100. Lesser = 2100. Applied 2100.
Now, is there any chance the intended deductible applied on claim 1 is only up to the point where... e.g., maybe the family deductible counts only in-network credits? If OON credits don't count toward family deductible, family remainder would be 3000 - 900 (A's 900 is... wait, A's 900 initial credit — is it in-network or OON? Unknown. It's just "deductible 900.00"). Hmm. The starting accumulators are just given as deductible credits without network attribution. Since the plan says credits accumulate to a single balance, they count regardless.
If the family deductible were only satisfied by in-network credits... that gets complicated. But the plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance" — so all credits go into one bucket. The family total is presumably the sum of member buckets. Family threshold 3000. So after claim 1, family = 3000, satisfied.
I think the intended flow: Claim 1 OON: A pays deductible 2100 + 120 coinsurance = 2220, plan 180. Family deductible met (3000). Claim 2 B: no deductible, 20% coinsurance = 260. Claim 3 A: no deductible, 20% = 360. Claim 4 A: no deductible, 40% OON = 640, plan 960.
Ending: A deductible 3000, OOPM 4120; B deductible 0, OOPM 260; family deductible 3000, family OOPM 4380.
Let me double check OOPM accumulation: Do deductible amounts and coinsurance both credit OOPM? Yes — OOPM is the ceiling on member cost share; all member cost share (deductible, coinsurance, copays) credits OOPM. A: 900 + 2220 + 360 + 640 = 4120. ✓. B: 0 + 260 = 260 ✓. Family: 4120 + 260 = 4380 ✓.
Check member_responsibility + plan_paid = allowed for claim 4: 640 + 960 = 1600 ✓.
Now the required keys: member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount, ending_deductible_a, ending_oopm_a, ending_deductible_b, ending_oopm_b, ending_family_deductible, ending_family_oopm.
Note the keys for ending accumulators have parenthetical annotations "(for A (subscriber))" and "(for B (spouse))" — those are just annotations, not part of key names. The key names are ending_deductible_a, ending_oopm_a, ending_deductible_b, ending_oopm_b, ending_family_deductible, ending_family_oopm.
Values:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
Numbers as plain with two decimals. The output contract says "Numbers are plain, two decimal places, no currency symbol." Should I emit them as JSON numbers (640.0 would render as 640.0)? JSON numbers: 640.00 is valid JSON (trailing zeros allowed? Yes, JSON numbers can have trailing zeros in the fraction part: 640.00 is valid JSON). Actually, JSON grammar: number = int frac? frac = "." 1*DIGIT — so "640.00" is valid. But some parsers will parse it as 640.0. The grader "parses the JSON block and compares fields against a gold answer" — likely numeric comparison. To be safe, emit numbers as JSON numbers with two decimals: 640.00. Hmm, but if the gold is a string "640.00"? Unknown. The instruction "Numbers are plain, two decimal places" — I'll write them as JSON numbers like 640.00, 0.00, 3000.00, etc. That preserves two decimal places in the raw text and parses as a number.
Alternatively, some harnesses want strings. But "Report every dollar amount as a plain number with two decimal places and no currency symbol" — plain number suggests numeric. I'll use numeric literals with two decimals.
Now let me re-verify claim 1 once more with careful attention to the embedded rule and the "lesser of" principle stated in the task family rules: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
A individual remainder (OON service): individual OON deductible 3000 - A balance 900 = 2100. Family remainder: family deductible 3000 - family credits 900 = 2100. Lesser = 2100. Deductible applied = min(2100, 2400 allowed) = 2100. ✓.
One more consideration: could the harness intend that for OON services, the family deductible remainder is measured differently? There's only one family deductible (3000, in-network). I'll go with 2100.
Also consider: is it possible that the intended adjudication treats the deductible applied on claim 1 as capped at 1500 (individual in-network) because... no, the service is OON; the threshold is the OON amount. The plan explicitly says the single balance is measured against the OON threshold when the service is out-of-network.
Hmm, wait. Let me reconsider: "Out-of-network (individual) 3000.00" — is this the amount the member must meet before the plan pays for OON services, measured against the single combined balance? Yes: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." So for an OON service, the member's combined balance must reach 3000 before the plan pays. A at 900, so 2100 more needed. ✓.
Claim 4: A's balance is 3000 ≥ 3000, so OON deductible satisfied; no deductible applied. ✓.
Also check: could claim 3 (in-network) have any deductible? A's balance 3000 ≥ 1500 in-network threshold; family 3000 ≥ 3000. No deductible. ✓.
Claim 2: B balance 0 < 1500 individual; but family remainder 0 → lesser = 0 → no deductible. This is the embedded "whichever comes first" — family deductible already satisfied by A's claims. ✓. That's the classic embedded-deductible gotcha being tested here.
So final answer as computed.
One more sanity check on coinsurance for claim 4: OON 40% member of 1600 = 640. Plan 60% = 960. ✓.
Ending accumulators:
- A deductible: 3000.00 (single balance; measured against 1500 IN / 3000 OON thresholds)
- A OOPM: 4120.00
- B deductible: 0.00
- B OOPM: 260.00
- Family deductible: 3000.00
- Family OOPM: 4380.00
Output JSON with exactly the required keys. No extra keys.
Format: single fenced JSON code block, nothing else.
Double-check key names: "member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount, ending_deductible_a, ending_oopm_a (for A (subscriber)), ending_deductible_b, ending_oopm_b (for B (spouse)), ending_family_deductible, ending_family_oopm".
So 11 keys.
Values with two decimals as JSON numbers.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 780 tokens
CLAIM 1 — A, OON, allowed 2400. Deductible OON individual 3000. Member deductible balance accumulates (single balance). A's deductible credit 900. Family deductible 900.
OON deductible threshold: 3000. Remaining 2100. Claim 2400: apply 2100 to deductible, remaining 300 goes to coinsurance at 40%. Coinsurance = 120.00. Member resp = 2100 + 120 = 2220. Plan = 180. OOPM A: 900 + 2220 = 3120. OON OOPM individual 12000.
Deductible: A individual balance now 3000? Wait — embedded structure. Single member deductible balance measured against threshold depending on network. A's deductible credit: 900 + 2100 = 3000. Family deductible: 900 + 2100 = 3000 → family deductible satisfied (3000).
Actually the deductible applied: 2100. A's deductible accumulator = 3000.
CLAIM 2 — B, in-network, allowed 1300. Family deductible already satisfied (3000). Embedded: individual B deductible 1500 not satisfied, but family deductible satisfied means... Under embedded structure, "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." So family deductible satisfied → B pays no deductible. B goes to coinsurance: 20% of 1300 = 260. Member resp 260, plan 1040. B OOPM = 260. B deductible accumulator: does deductible credit apply? Family deductible is satisfied, so no deductible applied. B deductible stays 0. Family OOPM: 900+2220+260 = 3380.
CLAIM 3 — A, in-network, allowed 1800. A's deductible balance 3000. In-network individual threshold 1500 — A's balance 3000 > 1500, satisfied. Family satisfied. So coinsurance 20% of 1800 = 360. Member resp 360, plan 1440. A OOPM = 3120 + 360 = 3480. Family OOPM = 3740.
CLAIM 4 — A, OON, allowed 1600. Deductible: A's balance 3000 ≥ 3000 threshold → satisfied. Coinsurance 40% of 1600 = 640. Member resp 640, plan 960. A OOPM = 3480 + 640 = 4120. Family OOPM = 3740 + 640 = 4380.
Deductible accumulators: A deductible = 3000 (no change). B = 0. Family = 3000.
OOPM check: A individual OON OOPM is 12000; in-network 6000. A's OOP 4120 < 6000, fine. Family OOPM 12000 (in-network)... family 4380, fine.
Required keys: member_responsibility (claim 4) = 640.00, plan_paid = 960.00, deductible_applied = 0.00, copay_amount = 0.00, coinsurance_amount = 640.00, ending_deductible_a = 3000.00, ending_oopm_a = 4120.00, ending_deductible_b = 0.00, ending_oopm_b = 260.00, ending_family_deductible = 3000.00, ending_family_oopm = 4380.00.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 6,401 tokens
Let me work through this carefully.
Plan: Bluebonnet PPO 1500, plan year 2026.
Deductible:
- Individual in-network: 1500.00
- Family in-network: 3000.00
- Structure: EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
- Out-of-network (individual): 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
Hmm, this is an interesting structure. Let me parse: there's a single member deductible balance that accumulates both in-network and out-of-network credits. The threshold that balance is measured against:
- For in-network services: 1500.00 (individual)
- For out-of-network services: 3000.00 (individual)
Family deductible: 3000.00 (in-network). Hmm, is there a family out-of-network deductible? Not stated. Family deductible is 3000.00. Actually the family deductible listed is "Family (in-network) 3000.00". There's no out-of-network family amount given. Hmm. The out-of-network individual is 3000.00.
Interesting: family deductible 3000.00 equals out-of-network individual 3000.00.
OOPM:
- Individual in-network: 6000.00
- Family in-network: 12000.00
- Individual out-of-network: 12000.00
So OOPM is also a single balance per member? The plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance" — that's for deductible. For OOPM, the document says individual in-network 6000, individual out-of-network 12000. Hmm, similar structure: perhaps the member OOPM balance accumulates both, with threshold 6000 for in-network and 12000 for out-of-network? The document doesn't explicitly say for OOPM that it's a single balance, but by analogy... Actually, let me think. The plan document says:
"Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year."
It doesn't specify separate OOPM balances. Given the deductible uses a single balance, I'd assume the OOPM also uses a single member balance measured against 6000 for in-network services and 12000 for out-of-network services. But let's check whether it matters in this problem.
Family OOPM: 12000.00. Family deductible: 3000.00.
Cost share:
- Coinsurance after deductible, in-network: 20% member / 80% plan
- Coinsurance after deductible, out-of-network: 40% member / 60% plan
- Copays (various) — not relevant here since these are procedures/imaging/diagnostic studies, not office visits, urgent care, ER, or pharmacy. So no copays in this problem. copay_amount = 0.00 for Claim 4.
Preventive care — not relevant.
Basis of payment: member cost share from ALLOWED amount.
Starting accumulators (before Claim 1):
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family total: deductible 900.00, OOPM 900.00
Claim 1 — 2026-05-05 — A, out-of-network specialist procedure. Billed 4440.00, allowed 2400.00.
Out-of-network service. A's deductible balance: 900.00. Threshold for out-of-network: 3000.00 (individual). So deductible not yet met for OON. A must pay deductible remainder: min(allowed, threshold - balance) = 3000 - 900 = 2100. Allowed is 2400, so 2100 goes to deductible. Remaining: 2400 - 2100 = 300, subject to 40% coinsurance = 120.00 member, plan 60% = 180.00.
Wait — but under an embedded structure: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Family deductible is 3000.00 in-network. Family total deductible credit is currently 900.00. Family remainder = 3000 - 900 = 2100. A's individual OON remainder = 3000 - 900 = 2100. Lesser = 2100. So deductible applied = 2100.
Hmm wait, but should the family deductible threshold for an out-of-network service be different? The family deductible listed is "Family (in-network) 3000.00". There's no family out-of-network deductible. Hmm. In this synthetic plan, the family deductible is 3000.00, and A's OON individual threshold is also 3000.00. So for claim 1, individual remainder (OON) = 2100, family remainder = 2100. Same.
So Claim 1: member responsibility = 2100 (deductible) + 120 (coinsurance) = 2220.00. Plan paid = 2400 - 2220 = 180.00.
Check OOPM: A's OOPM balance 900 + 2220 = 3120. Individual in-network OOPM 6000, individual OON 12000. Balance 3120 < 6000, so no OOPM cap hit.
Update accumulators:
- A deductible: 900 + 2100 = 3000.00. Wait — but A's individual in-network deductible is 1500.00. The deductible balance is a SINGLE member balance. So A's deductible balance is now 3000.00? Hmm, that's a question: does the deductible balance accumulate past the threshold? Yes, the balance accumulates; the threshold is what it's measured against. But for family deductible purposes, the family credit is what counts toward the family amount.
Hmm, wait. Let me reconsider. The "deductible" accumulator for a member — is it capped at the individual deductible amount? Under embedded structures, typically each member's deductible credit counts toward the family deductible up to the individual amount... Actually in real life, for embedded deductibles, each member's spending counts toward the family deductible, and once the family total reaches the family amount, everyone's deductible is met. Individual members meet their own deductible at the individual amount.
Here, the plan says the deductible is a single member balance accumulating both in-network and OON credits, measured against 1500 for in-network services and 3000 for out-of-network services. So the member balance could go to 3000 (if all OON) — the balance isn't capped; but for reporting "ending_deductible_a", what do we report? The running year-to-date total of deductible credits (accumulated cost share that credits the deductible). The glossary says: "Accumulator: the running year-to-date total of a member's deductible or OOPM."
So ending_deductible_a is the running YTD total of A's deductible credits. But should it be capped at the individual deductible? Hmm. This is ambiguous. Let me think about what's most sensible.
Actually, let's think: after claim 1, A's deductible balance = 3000.00 (900 + 2100). That's A's YTD deductible credit. For claim 3 (in-network), A's deductible threshold in-network is 1500, and balance 3000 ≥ 1500, so no deductible applies; coinsurance 20% applies.
For the family deductible: family total = 900 + 2100 = 3000.00. Family deductible is 3000.00 — met. So after claim 1, family deductible is satisfied. That means for claim 2 (B, in-network imaging), B's deductible... under embedded structure, "the family deductible is also satisfied once total family credits reach the family amount, whichever comes first". Family deductible met → B's deductible is satisfied (family met). So B pays no deductible, just 20% coinsurance.
Let me check: Claim 2 — B, in-network outpatient imaging, allowed 1300.00. Family deductible met (3000 of 3000). So B's individual deductible is satisfied via family. Member coinsurance = 20% of 1300 = 260.00. Plan pays 1040.00.
B's OOPM: 0 + 260 = 260.00.
B's deductible credit: hmm. Does B get deductible credit? B didn't pay any deductible — coinsurance doesn't credit the deductible. So B's deductible balance stays 0.00? Or does the "deductible satisfied" via family mean B's deductible shows as met but the credit is 0?
The accumulator is "the running year-to-date total of a member's deductible" — meaning the deductible credits. B paid no deductible amount, so B's deductible credit remains 0.00. Family deductible total remains 3000.00.
Hmm, but wait. Actually, let me reconsider whether the family deductible is met after claim 1. Family deductible (in-network) is 3000.00. Claim 1 was out-of-network, but the deductible credits accumulate to a single member balance — in-network and out-of-network credits accumulate to a single member deductible balance. Does an OON credit count toward the family (in-network) deductible of 3000? The plan says credits accumulate to a SINGLE member deductible balance. The family deductible threshold is 3000. I think family total credits = sum of member credits = 900 + 2100 = 3000. So family deductible met.
Hmm, but one could argue the family deductible is in-network only, so OON credits don't count toward it. But the plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance" — implying there aren't separate in-network/OON deductibles; there's one deductible balance per member. The family deductible is just 3000. So family total = sum of member balances. After claim 1: 3000. Family deductible met.
OK so Claim 2: B, in-network imaging, allowed 1300.
- B's individual deductible: not met individually (0 credits), but family deductible met (3000/3000). Embedded: individual deductible satisfied on its own OR family deductible satisfied, whichever comes first. Family came first → B's deductible is satisfied.
- Member: 20% coinsurance = 260.00. Plan: 1040.00.
- B's OOPM: 260.00.
- B's deductible credit: 0.00 (no deductible paid).
- Family OOPM: 900 (A) + 2220 (A) + 260 (B) = wait, family OOPM was 900 before. After claim 1: 900 + 2220 = 3120. After claim 2: 3120 + 260 = 3380.00.
- Family deductible: 3000.00 (met).
Claim 3 — 2026-06-14 — A, in-network follow-up procedure, allowed 1800.00.
- A's deductible balance: 3000.00. In-network threshold 1500 — exceeded. Also family met. So no deductible.
- Coinsurance 20%: 360.00 member, plan 1440.00.
- A's OOPM balance: 3120 + 360 = 3480.00. Below 6000 in-network individual OOPM. Fine.
- Family OOPM: 3380 + 360 = 3740.00.
- Family deductible: 3000.00 (unchanged, no deductible credit).
Claim 4 — 2026-07-08 — A, out-of-network diagnostic study, allowed 1600.00.
- A's deductible balance 3000.00 ≥ OON threshold 3000.00 → deductible satisfied. Family also met. No deductible.
- Coinsurance OON: 40% member = 640.00, plan 60% = 960.00.
- A's OOPM balance: 3480 + 640 = 4120.00. Individual OON OOPM threshold is 12000; in-network 6000. Balance 4120 < 6000 < 12000, so no cap.
- Family OOPM: 3740 + 640 = 4380.00. Family OOPM threshold 12000 (in-network). Not reached.
So Claim 4:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
Ending accumulators:
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
Check: member_responsibility + plan_paid = 640 + 960 = 1600 = allowed. ✓.
Now let me double-check the deductible_applied on claim 4: 0.00. Yes — A's single deductible balance is 3000.00, which meets the OON threshold of 3000.00 exactly. Family deductible also met.
Let me double check Claim 1's deductible computation more carefully. A's balance before: 900.00. OON individual threshold: 3000.00. Remainder: 2100.00. Allowed: 2400.00. Deductible applied = min(2100, 2400) = 2100.00. Family remainder: family deductible 3000.00 - family credits 900.00 = 2100.00. Embedded rule: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." The task family rules say: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Individual remainder = 2100 (OON: 3000-900), family remainder = 2100 (3000-900). Lesser = 2100. So deductible applied = 2100.00.
Hmm wait, actually there's a subtlety: is the "individual remainder" for the OON service measured against the OON individual threshold (3000) or the in-network individual threshold (1500)? The service is out-of-network, so the threshold the balance is measured against is 3000. So remainder = 3000 - 900 = 2100. Family remainder = 3000 - 900 = 2100. Deductible = 2100. Then family credits reach 3000 → family deductible met.
Alternatively, if someone used in-network individual threshold 1500: remainder = 600. Then deductible applied = 600, and the remaining 1800 subject to 40% coinsurance = 720. Member = 1320. Then A's balance = 1500. Family = 1500. Then claim 2: B's deductible remainder = min(1500 individual, 1500 family) = 1500... wait family remainder = 3000 - 1500 = 1500; individual remainder 1500. Deductible applied = min(1300, 1500) = 1300. B pays 1300 deductible, no coinsurance. Member = 1300. B deductible = 1300. Family deductible = 2800. Then claim 3: A's individual remainder = 1500-1500 = 0... A's balance 1500 ≥ in-network 1500 → no deductible. 20% of 1800 = 360. A OOPM = 900 + 1320 + 360 = 2580. Claim 4: A's balance 1500 < OON threshold 3000. Remainder = 1500. Family remainder = 3000 - 2800 = 200. Lesser = 200. Deductible applied = 200. Remaining 1400 × 40% = 560. Member = 760. Hmm, that's a different answer: member_responsibility 760, plan 840, deductible 200, coinsurance 560.
Which interpretation is right? The plan document says: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." The "amount above" refers to "Out-of-network (individual) 3000.00". So when the service is out-of-network, the member's deductible balance is measured against 3000.00. That's clear: for OON services, the threshold is 3000. So A's remainder for claim 1 = 3000 - 900 = 2100. The first interpretation is correct.
Also the embedded rule and the task instruction "a member's deductible is satisfied by the lesser of their individual remainder and the family remainder" — individual remainder measured against the applicable threshold for the service. So 2100.
Hmm, but wait — there's another subtlety with the family deductible. The family deductible is stated as "Family (in-network) 3000.00". Is there a family OON deductible? Not stated. Since the member balances are single (not split by network), the family total is just the sum. The family threshold is 3000. For OON services... hmm, there's no family OON threshold given. I'll treat family deductible as 3000 regardless of network, since the plan gives a single family deductible amount and member credits are combined into one balance.
Actually, hold on. Let me reconsider: does the family deductible of 3000 apply as a cap for OON services too? For claim 1: individual remainder (OON) = 2100, family remainder = 2100. Either way, 2100. Same result. Fine.
Now, claim 4: A's balance 3000 ≥ OON threshold 3000 → satisfied. Also family met. So deductible 0, coinsurance 40% of 1600 = 640.
Let me also double check the OOPM logic for claim 1: A's OOPM before: 900. Claim 1 member responsibility: 2220. New balance: 3120. Is the OOPM threshold for an OON service 12000 (individual OON)? The document lists individual OOPM in-network 6000, out-of-network 12000. By analogy with the deductible (single balance measured against the applicable threshold), the OOPM balance 3120 measured against 12000 for OON service — not reached. So full member responsibility applies. Even if measured against 6000, not reached. So no issue.
Claim 2: B's OOPM: 0 + 260 = 260. Fine.
Claim 3: A: 3120 + 360 = 3480. In-network threshold 6000. Not reached.
Claim 4: A: 3480 + 640 = 4120. OON threshold 12000; also < 6000. Not reached either way. Fine.
Family OOPM: 900 + 2220 + 260 + 360 + 640 = 4380. Family threshold 12000 (in-network). Not reached.
Now, ending deductible for A: 3000.00. Hmm — should A's deductible accumulator be capped at 3000 or should it be reported as the full credit? A's credits: 900 (before) + 2100 (claim 1) = 3000. No further deductible credits (claims 3 and 4 had no deductible). So 3000.00.
B's deductible: 0.00. B paid only coinsurance, which doesn't credit the deductible.
Family deductible: 900 + 2100 = 3000.00.
Hmm, wait — but should the family deductible be capped at 3000? It is exactly 3000. Fine.
But here's a subtle question: does B's "deductible satisfied" status mean B's deductible accumulator should show something? No — the accumulator is the running YTD total of deductible credits, which is 0.00 for B. The deductible being "satisfied" via family doesn't create credits for B.
Actually, hmm, wait. Let me reconsider. Some plans, when the family deductible is met, treat each member's deductible as met. The accumulator "ending_deductible_b" = 0.00 is the credit total. I think 0.00 is right.
Let me reconsider claim 2 more carefully though. B, in-network imaging, allowed 1300. Family deductible met (3000/3000 after claim 1). Embedded structure: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." So the family deductible being satisfied means every member's deductible is satisfied. So B pays no deductible, only 20% coinsurance = 260. Plan = 1040.
Check: 260 + 1040 = 1300 ✓.
But wait — is there a nuance where the family deductible applies to in-network services and claim 1's OON credit shouldn't count toward the family in-network deductible? Let me re-read: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." This strongly implies one deductible balance per member, not two. The thresholds differ by network: 1500 (in-network individual), 3000 (OON individual), 3000 (family). The family deductible is just 3000, listed under "Family (in-network)" — hmm, the "(in-network)" label is a bit odd. But given there's no family OON amount and the credits combine into a single balance, I'll treat family deductible 3000 as the family threshold regardless.
Actually, hmm, let me think about this differently. What if the intended reading is: the family deductible of 3000 applies, and since credits combine, family total after claim 1 = 3000. Either way, same.
But consider the alternative: if OON credits did NOT count toward the family in-network deductible, then after claim 1, family in-network deductible credit = 900 (only the pre-existing 900, which we don't know the network provenance of). The problem states initial accumulators without network breakdown, so we can't split. The plan document's single-balance rule tells us not to split. So family total = 3000 after claim 1. Family deductible met.
OK here's another consideration for claim 1: does the ER copay or any copay apply? No — it's a specialist procedure, not an office visit. Specialist office visit copay 60.00 applies to office visits; this is a "specialist procedure" out-of-network. Hmm, "Out-of-network specialist procedure" — is this an office visit with a specialist? It says "procedure", so I'd say no copay; it's subject to deductible and coinsurance. Also, copays typically apply in-network; this is OON. The plan lists copays under "Member cost share" without specifying network, but the preventive care section says "In-network preventive services..." — copays are presumably in-network benefits. For OON, deductible/coinsurance applies. I'll treat claim 1 as deductible + coinsurance, no copay.
Similarly claim 3 "In-network follow-up procedure" — a procedure, not an office visit. No copay. Deductible/coinsurance. Claim 4 "Out-of-network diagnostic study" — no copay.
So the answer:
Claim 4:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
Ending:
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- endijson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Qwen3.8 Max · Alibaba242.0s · 9,590 out | 237.2s · 11,183 out | 213.2s · 8,673 out
Reasoning · 9,403 tokens
We need answer JSON only. Need solve carefully. We have plan document. Need adjudicate claims 1-4 in order, update accumulators. Need report components for Claim 4 and ending accumulators.
Important: Deductibles embedded, in-network indiv 1500, family 3000. Out-of-network individual deductible threshold 3000. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is threshold measured against when service is out-of-network. OOPM: individual in-network 6000, family in-network 12000, individual out-of-network 12000. Once member reaches OOPM plan pays 100% allowed for covered services remainder plan year. Need understand OOPM accumulators? Starting: A deductible 900, OOPM 900. B 0. Family total deductible 900 OOPM 900. This likely year-to-date credits, not remaining. They say accumulators. Need compute ending deductible/oopm probably credits totals? Need infer. They ask ending_deductible_a etc. Starting given as deductible 900 out-of-pocket 900. Likely accumulator balances (amount applied toward deductible / OOPM). We need output ending accumulator balances (amount accumulated). Need be careful if out-of-network separate OOPM? They give individual OOPM out-of-network 12000 but starting OOPM is maybe single? Plan doc says individual in-network 6000, family in-network 12000, individual out-of-network 12000. Does OOPM have separate in-network and out-of-network accumulators? Starting out-of-pocket 900 maybe in-network? Need decide.
Task: FAMILY ACCUMULATORS as of moment before Claim 1:
A deductible 900 out-of-pocket 900
B 0 0
Family total deductible 900 out-of-pocket 900.
No network split. Claim 1 out-of-network. Deductible: single balance measured against OON threshold 3000. OOPM: individual out-of-network 12000. Does OON cost share credit a separate OON OOPM, or also general? Document: "Out-of-pocket maximum Individual (in-network) 6000; Family (in-network) 12000; Individual (out-of-network) 12000. Once a member reaches the out-of-pocket maximum..." It doesn't explicitly say single OOPM balance. Starting has one out-of-pocket accumulator. But if OON services have separate OOPM, maybe need track? Required keys only ending_oopm_a, ending_oopm_b, ending_family_oopm, likely one value. Need determine from plan language.
Maybe out-of-pocket accumulators count all member cost share (deductible+coinsurance+copays) but network-specific maximums? Could be a single accumulator with threshold depending on network of service? Let's parse: Deductible: in-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is threshold that balance is measured against when service is out-of-network. That means one deductible credit balance; for in-network service threshold 1500, for OON threshold 3000. For OOPM, it doesn't say single. It lists individual in-network, family in-network, individual out-of-network. Might imply separate OOPM accumulators by network? But starting only out-of-pocket one. Could be in-network OOPM accumulator only? Hmm.
We need compute Claim 4. Let's step through possibilities.
Plan details:
- Deductible individual in-network 1500; family 3000 embedded.
- OON individual deductible 3000. In-network and out-of-network deductible credits accumulate to single member deductible balance. So A has deductible credit 900 starting.
- For each claim, member deductible applied = lesser allowed amount? But embedded family limit.
Need adjudicate claim 1: A OON specialist procedure allowed 2400.
A starting deductible balance 900. OON deductible threshold 3000. Remaining OON deductible = 3000 - 900 = 2100. Allowed 2400. Deductible applied = min(2400,2100)=2100? But family deductible? Structure embedded; family deductible also satisfied once total family credits reach family amount. But family in-network deductible 3000. For OON, family deductible? Not specified. It only gives OON individual 3000. No OON family deductible. Probably family deductible applies in-network? Maybe OON no family deductible? Or family total threshold? We need use family accumulator? "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Family remainder likely family deductible amount (in-network 3000) minus family credits. But for OON service, individual threshold is 3000, family threshold? Could still family 3000? Plan says Family (in-network) 3000. Out-of-network individual 3000; no family OON. Maybe family deductible only in-network. However rules for whole family: family accumulator moves on every claim that generates cost share. Need know family deductible amount for OON? Could be 3000? Since OON individual =3000 and family in-network=3000. Maybe family OON not stated; maybe use family in-network? But out-of-network threshold measured against service is OON individual. Hmm.
Claim 1 OON allowed 2400. Starting A deductible balance 900. If OON individual deductible 3000, remaining 2100. Deductible applied 2100, leaving A deductible credit 3000? Wait credit balance becomes 900+2100=3000. Then remaining allowed 300 subject to OON coinsurance 40% =120 member, plan 180. Member responsibility 2220, plan 180. OOPM credits? Deductible applied + coinsurance likely count toward OOPM. Copays count too. So A OOPM credit +2220. If OON separate OOPM threshold 12000, balance 3120? Starting 900 maybe maybe not. If single OOPM with threshold context? Hmm.
Family deductible credit +2100? Starting family deductible 900 -> 3000? But if only deductible applied, not coinsurance. Family deductible total can't exceed family amount? But family in-network amount 3000; if OON credits also count family? Then family deductible reaches 3000. If so family deductible satisfied.
Claim 2: B in-network outpatient imaging allowed 1300. Starting after claim1: B deductible 0, family deductible maybe 3000 satisfied. Under embedded, a member's deductible satisfied by lesser individual remainder and family remainder. If family deductible satisfied, B individual deductible considered satisfied? "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." If family deductible satisfied, all members? Usually when family deductible met, plan pays for all. But embedded: individual can satisfy own; once family met, remaining members no deductible. So B deductible applied 0? Then coinsurance 20% allowed =260 member, plan1040. If B had to satisfy individual deductible 1500, allowed 1300 all deductible. But family already met if claim1 counted 2100 to family plus starting 900 =3000. Then no deductible. Important.
If family deductible not updated by OON or not satisfied? Let's explore.
Alternative claim1 family deductible applied maybe min(allowed, family remainder?) Family in-network remainder 3000-900=2100. Deductible applied 2100 (same). Family reaches 3000. So B claim2 no deductible. If family OON threshold maybe? same 3000. So yes.
Claim3: A in-network follow-up allowed 1800. A deductible balance after claim1: if OON deductible threshold 3000, balance 3000, individual in-network deductible 1500 already satisfied because balance >=1500. So no deductible. Coinsurance 20%=360 member, plan1440. OOPM +360.
Claim4: A OON diagnostic allowed 1600. A deductible balance 3000 (satisfied OON individual threshold 3000). No deductible. OON coinsurance 40%=640 member, plan960. Member resp 640, plan paid 960. Deductible_applied 0, copay 0, coinsurance 640. Ending accumulators: A deductible credit? Single balance may increase only by deductible applied. It stays 3000? But deductible credits maybe for OON threshold single balance, no more after threshold? It could be 3000. OOPM A starting 900 + claim1 2220 + claim2? claim2 B not A + claim3 360 + claim4 640 = 4120? Wait 900+2220=3120; +360=3480; +640=4120. If OOPM single. Family OOPM: start900 + A claim1 2220 + B claim2 260 + A claim3 360 + A claim4 640 = 4380. B ending deductible: B credit 0? If no deductible applied. B OOPM 260. Family deductible: 3000 (starting 900 + claim1 2100; no more). But need check if B claim2 would apply deductible if family not met? If family met, no.
But there are tricky aspects: out-of-network OOPM separate. If OON OOPM accumulator separate, starting out-of-pocket 900 maybe in-network? Then Claim1 OON cost share 2220 credits OON OOPM separately =2220? Ending_oopm_a might need combined or in-network? Required only one value; maybe total out-of-pocket credits across all? Let's examine plan language and harness expectations.
The task family likely tests benefit math with embedded deductible and network-specific OOPM? They may expect handling out-of-network deductible threshold and OON OOPM separate? But output keys only one ending_oopm per member/family. They might track out-of-pocket accumulator as single credit total, with threshold varying by service? But if thresholds differ, how to know if OOPM reached? Could use a single balance but compare to network-specific threshold for current claim. Starting 900. If single balance counts all cost share, after claim1 balance 3120; for OON threshold 12000 not reached. For in-network threshold 6000 not reached. So okay. At high amounts could diverge? If single balance includes OON and IN cost share, and OON threshold 12000, in-network threshold 6000. If single balance reaches 6000 due to mix, would plan pay 100% for in-network but not OON. But one balance can't represent both if OON continues. Unless service-specific threshold: for in-network, if total OOP balance >=6000, no cost share; for OON, if total >=12000. But if total=7000 from in-network, then for OON not met, but the in-network costs already counted; that's okay? But if then OON cost share adds to same balance, total grows. If total=10000, in-network would have been free after 6000, but OON still cost share until 12000. Single balance can work with threshold based on service network. However family OOPM in-network 12000; no family OON given. Maybe family OOPM applies in-network only; OON individual only. For family total, single balance threshold maybe 12000? Hmm.
But plan says "Once a member reaches the out-of-pocket maximum the plan pays 100% ...". It doesn't say network-specific separate accumulators. The OOPM amounts are by network. Could interpret as: In-network services have OOPM 6000 individual/12000 family; out-of-network services have individual OOPM 12000 (no family?). A single accumulator can be measured against the relevant threshold for service. But if member has both, cost sharing for in-network stops at 6000; OON continues until 12000. If single balance stops increasing for in-network after 6000? Actually once member reaches in-network OOPM, plan pays 100% of allowed for covered services for remainder of plan year—not just in-network? Wording says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for remainder". Could be if reaches any applicable OOPM? That would mean if reaches in-network 6000, even OON covered 100? That seems unlikely. Usually OON separate higher OOPM, in-network OOPM only applies in-network. But synthetic doc may simplify.
Need identify intended from task. Starting accumulators are labeled "out-of-pocket" not split. They likely expect one OOPM accumulator. The plan doc: "Out-of-pocket maximum Individual (in-network) 6000; Family (in-network) 12000; Individual (out-of-network) 12000." It might mean there are separate OOPM thresholds but accumulators? They didn't explicitly say single like deductible. Could be they expect OON OOPM separate. But required keys only ending_oopm_a, maybe maybe ending in-network/out-of-pocket total? Need infer from typical harness.
Let's inspect wording: "Deductible ... In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." This explicitly solves deductible single balance. For OOPM they did not say single. But they gave starting accumulator "out-of-pocket" not "in-network out-of-pocket". Maybe to keep simple, one OOPM balance, thresholds depend on network? If they intended separate, they'd have given separate starting OOPM or keys.
Need calculate with possible alternative: If OON OOPM separate, ending_oopm_a maybe what? Could be combined? Let's explore.
Maybe the OOPM accumulator is for in-network only? Starting A OOPM 900. Claim1 OON cost share may not credit in-network OOPM? But plan says copays always credit OOPM; doesn't specify network. Out-of-network OOPM exists, so OON cost share credits OON OOPM. If output only one ending_oopm, maybe they want total out-of-pocket across both networks (sum of in-network and out-of-network credits). Then ending_oopm_a = same as single total 4120. If separate, total same (unless threshold cap? no). B total 260. Family total 4380. So maybe same anyway because no OOPM reached. Unless OON cost share not credit family/in-network OOPM? But family total maybe includes all. Hmm. Since thresholds not reached in this sequence, the exact network split doesn't affect accumulator credits if all cost share counts to OOPM. Unless out-of-network cost share doesn't count toward family OOPM? But likely counts to individual OON OOPM and maybe not family in-network; but required family_oopm? Starting family OOPM 900 maybe total. Need output total.
Need verify claim2 deductible due to family embedded and OON credits. Does out-of-network deductible credit count toward family in-network deductible? "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." Family accumulator moves on every claim. The family deductible amount is in-network 3000; no OON family. If A OON deductible applied 2100, family deductible credit moves by 2100. So family met. This could be intended. But maybe out-of-network deductible does NOT credit family deductible? Then claim2 B would have deductible 1300. Need examine: Plan says family (in-network) 3000. Structure embedded. Out-of-network (individual) 3000. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. That is for member. Does OON deductible credit count toward family? "A member's own accumulator and the family accumulator both move on every claim that generates cost share." That says yes family accumulator moves on OON claim if generates cost share. "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." So family remainder applies. So family deductible after claim1 should be 3000 (if deductible applied 2100). Therefore claim2 no deductible.
But need check A deductible applied in claim1 limited by family remainder? Starting family deductible credit 900, family amount 3000 -> family remainder 2100. A individual OON remainder = 3000-900=2100. Lesser =2100. Allowed 2400, so deductible applied 2100. Good.
Now OOPM and plan paid for claim1: After deductible, remaining allowed 300, coinsurance OON 40%=120. Plan pays 60%=180. Member resp 2220. OOPM credits: deductible 2100 + coinsurance 120 =2220. Copay 0. Good.
Claim2: B in-network outpatient imaging allowed 1300. Since family deductible satisfied? Let's compute individual B remainder: individual in-network deductible 1500 - B credits 0 =1500. Family remainder: family amount 3000 - family credits 3000 =0. Lesser =0. Deductible applied 0. Coinsurance in-network 20% of allowed =260. Plan 1040. Member resp 260. OOPM B +260. Family OOPM +260. Does family deductible move? Deductible applied 0 so no. B deductible balance remains 0? Or if family met, B considered satisfied but no credits. Accumulator is credits, not status; ending_deductible_b likely 0. Could there be a notional deductible applied equal to allowed even if family met? No, deductible applied should be amount applied to deductible. If deductible satisfied via family, no deductible applied. Could B's individual deductible accumulator become 1300? No, no cost share applied to deductible. But maybe under embedded, once family deductible met, individual deductible is satisfied but accumulator remains actual credits. Starting family credits include A's. B has no own credits. Ending_deductible_b 0. Is that expected? They ask ending deductible for every member; likely amount accumulated toward own deductible, so B 0. Could they expect B deductible 1300 if individual deductible would have been applied but family met? No, that would double count? Let's think. In family embedded plan, each member's individual deductible is met when their own expenses equal individual deductible OR family deductible met. The individual deductible accumulator often tracks member's allowed expenses toward deductible, but if family deductible met first, member may be shown as deductible met but not with own credits. The prompt says "FAMILY ACCUMULATORS" with A deductible 900 B 0 Family total 900. This likely tracks actual deductible credits per member and total. So B remains 0 if no deductible applied. Ending_family_deductible remains 3000.
But could family deductible total cap at 3000 and not include B's cost share after met. Yes.
Claim3: A in-network follow-up allowed 1800. A's individual in-network deductible satisfied because A single deductible balance 3000 >=1500. Family satisfied. Deductible 0. Coinsurance 20% =360. Plan 1440. OOPM A +360. A OOPM total 900+2220+360=3480.
Claim4: A out-of-network diagnostic allowed 1600. Need OON deductible threshold 3000. A single deductible balance 3000 => deductible satisfied for OON too (threshold 3000). Deductible 0. Coinsurance OON 40% =640. Plan 960. Member resp 640. OOPM A +640 =4120. Family OOPM +640 =4380.
Need ensure OOPM not reached for A? 4120 <6000 in-network, <12000 OON. So no change.
Now output required keys:
member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount,
ending_deductible_a, ending_oopm_a, ending_deductible_b, ending_oopm_b, ending_family_deductible, ending_family_oopm.
For Claim 4 components: member_responsibility=640.00? plan_paid=960.00; deductible_applied=0.00; copay_amount=0.00; coinsurance_amount=640.00.
Ending values as above: ending_deductible_a=3000.00? Need consider single member deductible balance can exceed threshold? It reached exactly 3000. Claim3/4 no deductible. So 3000.00. ending_oopm_a=4120.00. ending_deductible_b=0.00. ending_oopm_b=260.00. ending_family_deductible=3000.00. ending_family_oopm=4380.00.
Need ensure family deductible cap maybe family amount 3000. Yes. But if A's OON deductible applied 2100, starting family 900 =>3000. Good.
Let's double-check if claim1 deductible applied could be 1500 instead of 2100 because individual in-network deductible amount? No, OON threshold 3000. Starting deductible balance 900. If service OON, threshold measured 3000. So remaining 2100. Allowed 2400. Deductible 2100. Yes.
Could family deductible amount for OON be not 3000 but maybe family OON not exists; if no family OON, family accumulator might not move on OON? But family rules say both move. If family OON amount not specified, perhaps family deductible only applies to in-network, so OON deductible applied to member only and family deductible does not move? Then after claim1 family deductible remains 900; claim2 B would apply deductible: family remainder =2100, B individual remainder=1500, allowed=1300 => deductible applied=1300. Then B no coinsurance; member resp 1300, plan0. B deductible balance 1300, family deductible 2200. Claim3 A in-network: A single balance? Claim1 3000? If OON individual threshold met, yes no individual deductibljson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 10,996 tokens
We need answer with JSON only. Need solve claims sequentially under plan. Need be careful. Need produce required keys only. Let's analyze thoroughly.
Plan: Bluebonnet PPO 1500. Plan year 2026. Deductible individual in-network 1500, family 3000 embedded. Out-of-network individual deductible threshold 3000? Text: Out-of-network (individual) 3000.00. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is threshold measured when service is out-of-network. Need interpret accumulators: They provide deductible balances as of before Claim 1: A deductible 900, OOP 900; B 0; family total deductible 900, OOP 900. Likely these are credits accumulated? "ending_deductible" maybe accumulator balance? Need infer from required keys: ending_deductible_a likely deductible accumulator total (credits) or remaining? They say FAMILY ACCUMULATORS: A deductible 900 out-of-pocket 900. So accumulators are amounts accumulated toward deductible/OOPM, not remaining. Ending deductible should be updated accumulator credits. Need verify. They ask deductible_applied for Claim 4. We need compute components.
Important: Out-of-network deductible: single member deductible balance accumulates both in and out. Threshold for OON is 3000 individual. For in-network threshold 1500. Family deductible 3000 in-network? Out-of-network family? Not given except family in-network 3000. Structure embedded. But OON individual threshold 3000. How family deductible applies to OON? The plan doc only says individual OON 3000, in-network and out-of-network deductible credits accumulate to single member deductible balance; threshold above is measured against when service is out-of-network. It doesn't explicitly mention family OON deductible. Maybe family deductible is in-network only? But accumulators family total. Need decide.
OOPM: Individual in-network 6000, family 12000, individual out-of-network 12000. Once member reaches OOPM plan pays 100% allowed for covered services remainder. Do OON and IN OOPM separate? It says individual (in-network) 6000; individual (out-of-network) 12000. But initial accumulators OOP 900 maybe all? Need understand. They list one out-of-pocket per member, not separate. Maybe OON and IN credits accumulate to a single OOP accumulator but threshold depends on network? Or separate? Wording: "Out-of-pocket maximum Individual (in-network) 6000; Family (in-network) 12000; Individual (out-of-network) 12000. Once a member reaches the out-of-pocket maximum..." Could mean for OON services, the OOP maximum threshold is 12000 (individual), but same accumulator? It doesn't explicitly say single balance like deductible. Initial accumulators have one OOP. Need likely use single out-of-pocket accumulator with network-specific threshold? But if A has 900 OOP, is that toward IN or OON? We need compute claim 1 OON. For OON specialist procedure: not office visit? It's specialist procedure, no copay. Cost share: deductible then coinsurance 40% member /60 plan. Deductible threshold OON individual 3000. Starting A deductible accumulator 900. So remaining OON deductible? If single balance threshold 3000, remaining = 2100. Allowed 2400. Deductible applied = min(2400,2100)=2100. Remaining allowed after deductible=300. Coinsurance member 40%=120. Plan pays 60%=180. Member responsibility=2220. Plan paid=180. OOP credits: deductible 2100 + coinsurance 120 =2220? Copays no. Does OON cost share credit OOP? Usually yes, unless separate. Plan says once reaches OOPM plan pays 100 allowed for covered services; premiums/non-covered never count. Does not exclude OON. But individual OON OOPM 12000 maybe separate threshold. Initial OOP 900. Need update A OOP by 2220 => 3120 if single accumulator. But if OON OOPM separate from IN, maybe starting 900? The prompt's family accumulators likely one OOP value, so maybe single. But then threshold? Could be OON threshold 12000. Not met.
Claim 2: B in-network outpatient imaging, allowed 1300. B deductible accumulator 0, family deductible accumulator after claim1? Starting family deductible 900. Claim1 adds deductible 2100 => family deductible 3000. Family deductible satisfied. Embedded: individual satisfies own; family satisfied once total family credits reach family amount. For B in-network, deductible threshold individual 1500 and family remainder? Under embedded structure, member's deductible satisfied by lesser of individual remainder and family remainder. We need apply rule: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Hmm exact: Each claim updates member and family. Under embedded structure a member's deductible is satisfied by lesser of their individual remainder and family remainder. Need parse. If family deductible already satisfied (family accumulator=3000), family remainder=0. Individual B remainder =1500-0=1500. Lesser is 0, so deductible required 0. So B no deductible. Then coinsurance 20%? Since after deductible, member 20%. Allowed 1300, coinsurance=260, plan=1040. Member resp=260. B deductible accumulator? Does it increase if no deductible applied? Deductible applied 0, but cost share coinsurance. Deductible accumulator likely only deductible applied, so remains 0? But family accumulator? Does family deductible move on every claim that generates cost share, or only deductible applied? Text: "A member's own accumulator and the family accumulator both move on every claim that generates cost share." This could mean both deductible and OOP accumulators? But if no deductible applied, deductible accumulator doesn't move? "both move" ambiguous. In family embedded, when individual deductible satisfied by family? Let's reason.
Initial family total deductible 900. Claim1 deductible applied 2100 => family total 3000, satisfied. Claim2 B has cost share coinsurance but no deductible. Should family deductible accumulator increase? It can't exceed 3000? Maybe stays 3000. B deductible accumulator maybe remains 0 because no deductible paid. But embedded family deductible can be satisfied by any member's deductible payments. If B pays coinsurance after family deductible satisfied, not deductible. So no additional deductible credits. B OOP accumulator increases by coinsurance 260. Family OOP increases by 260. B deductible remains 0, family deductible remains 3000. Is that consistent with "own accumulator and family accumulator both move on every claim that generates cost share"? Maybe they mean OOP accumulators? Or deductible? They say under embedded structure a member's deductible is satisfied by lesser of individual remainder and family remainder. Could imply if family remainder less than individual remainder, the amount of deductible applied is family remainder. But if family remainder 0, deductible satisfied. "both move on every claim that generates cost share" maybe if deductible applies.
Alternative: For embedded family, when B has allowed 1300 and family deductible not satisfied? But it is satisfied. So no deductible. Good.
Claim3: A in-network follow-up procedure allowed 1800. A deductible accumulator after claim1? Starting 900 + 2100 =3000. Individual in-network threshold 1500, so A individual deductible satisfied. Also family satisfied. No deductible. Coinsurance 20%=360. Plan=1440. Member=360. OOP A increases 360. A OOP from 3120 to 3480 (if single). Family OOP from 900+2220+260+360? Let's compute: initial family OOP 900. Claim1 +2220 =>3120. Claim2 +260=>3380. Claim3 +360=>3740. A OOP 3480, B 260, total 3740. Good. Deductible A stays 3000? But in-network deductible accumulator could be capped at 1500? They gave starting A deductible 900. If A had 900 before, claim1 OON applied 2100 to single balance, total 3000. For in-network threshold 1500, balance can exceed threshold. Ending deductible_a maybe 3000. Or should we cap individual deductible accumulator at in-network individual deductible? The accumulator is "deductible" amount met; could exceed individual in-network because OON threshold is 3000. Since single member deductible balance, A balance 3000. But for in-network services, the deductible met is at least 1500; balance maybe 3000. They likely report actual accumulator credits. Starting family deductible 900; after claim1 3000; cap family at 3000. So ending family deductible 3000. A deductible 3000? But if individual in-network max is 1500, can individual deductible accumulator exceed 1500? Yes due to OON threshold 3000 single balance. The doc says single member deductible balance measured against OON threshold for OON. So yes 3000. But embedded family: family deductible is 3000. Individual A's in-network deductible satisfied at 1500, but the accumulator balance might be 3000. Need output ending_deductible_a likely accumulator balance, not remaining. The initial values: A deductible 900. If prior services were in-network maybe accumulator would not exceed 1500. But no matter.
Claim4: A out-of-network diagnostic study, allowed 1600. Need components. At this point A deductible balance? 3000. OON individual deductible threshold 3000. So deductible remaining = 0. Therefore no deductible applied. OON coinsurance 40% member after deductible. Member coinsurance = 40% * 1600 = 640. Plan paid = 960. Copay amount = 0. Member responsibility = 640. Does OOP maximum stop? Need check A OOP before claim4: 3480. Threshold for OON individual =12000? Or maybe in-network OOPM 6000? For OON service, threshold 12000. Not reached. If single accumulator with one OOPM? Maybe there is separate in-network and out-of-network? Need parse carefully. If A OOP 3480, even if threshold in-network 6000, not reached. So claim4 cost share applies. Add OOP 640 => A ending OOP 4120. Family OOP 4380. Deductibles unchanged: A 3000, B 0, family 3000.
But we need ensure claim1 OOP crediting, and whether OON deductible/coinsurance credits to OOPM. The plan says OOPM ceiling on member cost share. No exclusion except premiums/non-covered. Copays always credit. Deductible and coinsurance presumably credit. For OON, individual OOPM 12000. So yes.
Need maybe account for out-of-pocket maximum family 12000 in-network and individual OON 12000. The family total OOP maybe has threshold 12000 in-network? But not relevant.
Could there be a nuance: Out-of-network services may not credit in-network deductible/OOPM? But doc says single deductible balance for in/out. For OOPM not explicit. Starting accumulators single OOP. Could be single balance with thresholds. Need likely.
Need think about "Out-of-network (individual) ............ 3000.00" under deductible. "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." This implies for a member, one deductible balance. For in-network service, threshold 1500; for out-of-network, threshold 3000. If balance is 900 before claim1, then for OON claim remaining threshold 2100. Applied 2100, balance becomes 3000. For later in-network claim, threshold 1500, satisfied. For later OON claim, threshold 3000, satisfied. Good.
Family deductible: initial family total 900. Family (in-network) 3000 embedded. Is there a family OON deductible? Not listed. Maybe family deductible applies only in-network, but family total deductible credit accumulates from all deductible payments? The rule says family accumulator moves. Under embedded structure, individual satisfies individual on own; family deductible also satisfied once total family credits reach family amount. If OON claim A pays deductible 2100, family credits reach 3000. This satisfies family deductible. Does that affect B's in-network deductible? Yes no deductible.
But what if family deductible for OON is not satisfied? There is no family OON amount, maybe not applicable. But for B's in-network claim, family in-network deductible satisfied by A's OON deductible credits? The doc says total family credits reach family amount. Single balance? It says in-network and out-of-network deductible credits accumulate to single member balance. Family total probably sum of member balances. So yes.
Need ensure Claim1 member responsibility plus plan paid equals allowed: 2220+180=2400. Good. Claim2 260+1040=1300. Claim3 360+1440=1800. Claim4 640+960=1600.
But maybe Claim1 OON specialist procedure has specialist office visit copay 60? It says specialist office visit copay. Service is "Out-of-network specialist procedure" not office visit. Procedure subject to deductible/coinsurance. No copay.
Claim2 imaging not copay, subject deductible/coinsurance. Claim3 follow-up procedure not office visit. Claim4 diagnostic study not copay.
Need output only required keys: member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount, ending_deductible_a, ending_oopm_a, ending_deductible_b, ending_oopm_b, ending_family_deductible, ending_family_oopm. Values plain two decimals? JSON numbers can have decimals. Need include exactly. Could use numbers 640.00? JSON allows 640.00? Yes but some parsers accept. Better as number with two decimals? JSON number 640.00 valid. Could also use strings? They likely want plain numbers. Ground rule: report every dollar amount as plain number with two decimal places and no currency. In JSON, number literal 640.00 is okay, but if serialized may become 640? We can write 640.00. Ensure all have .00 or .xx.
Need verify ending OOPM values. Let's recalc with potential alternative: OOPM accumulators may be network-specific, and initial 900 could be in-network only? If so Claim1 OON cost share may go to OON OOP accumulator not shown? But prompt shows single out-of-pocket accumulator. It asks ending_oopm_a not separate. So likely single total. But could need apply OOPM threshold after each claim and cap cost share if reaches threshold. We need consider whether A's OOP after claim1 and claim3 could reach 6000? No.
Could out-of-network cost share not count toward in-network OOPM, but counts toward OON OOPM. If single output, maybe total OOP includes both? Starting 900 maybe from prior in-network? If separate, total would be? But no separate fields. Need likely total.
Potential nuance: Once family OOPM reached, plan pays 100% for covered in-network services? It says individual OOPM, family OOPM. Family OOPM 12000. Not relevant.
Potential nuance: Embedded deductible and family accumulator: Under embedded structure a member's deductible is satisfied by lesser of individual remainder and family remainder. We applied family remainder zero for B. But initial family total 900. Claim1 OON deductible applied 2100, but family deductible amount is 3000. Does family remainder after claim1 exactly zero? Starting family deductible accumulator 900. Add 2100 =3000. Yes.
But perhaps out-of-network deductible does NOT apply to family deductible (family in-network only). Then after Claim1 family deductible would remain 900? Then Claim2 B would have deductible applied up to individual B 1500 and family remainder 2100, lesser 1300? Allowed 1300 => deductible 1300, no coinsurance. Then B deductible=1300, family deductible=2200. Claim3 A in-network: A individual deductible? Starting A 900+OON 2100=3000; individual in-network satisfied; but family remainder 800? Under embedded, member's deductible satisfied by lesser of individual remainder and family remainder. For A, individual remainder 0 (since individual threshold 1500 satisfied). Lesser 0, so no deductible. Claim3 coinsurance. Family deductible stays 2200? Or if family accumulator moves on cost share? If deductible not applied no. Claim4 A OON: A deductible balance 3000 threshold 3000 satisfied; no deductible. Ending family deductible 2200. But is this plausible? The plan says family deductible is also satisfied once total family credits reach family amount. If OON deductible credits don't count to family, then family not satisfied. But "in-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance" and family total likely sum. Family deductible amount is in-network, but do OON credits count to family? It doesn't explicitly say. "Family total deductible 900" initial maybe includes A's prior OON/IN. The family deductible is 3000 in-network. In many plans, OON deductible separate and not count to in-network family. But this synthetic doc says single member balance for in/out, measured against OON threshold for OON. It doesn't say single family balance. However task family accumulators include family total deductible 900, likely total of member deductible balances. If A's OON deductible credits increase member balance, family total moves. The family deductible threshold is 3000. Since OON individual threshold also 3000, A's OON deductible fully satisfies family. Seems intended.
Need examine wording: "Deductible Individual (in-network) 1500; Family (in-network) 3000; Structure EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first. Out-of-network (individual) 3000.00. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." This strongly says all deductible credits (in and out) count in single member balance. Family total credits likely sum of member balances. Therefore OON credits count to family total. Good.
Potential nuance: For OON claim, individual deductible threshold 3000, but family deductible amount is 3000 and embedded. If family deductible was not satisfied before, could family cap limit deductible applied? The rule: under embedded, member's deductible is satisfied by lesser of individual remainder and family remainder. For A claim1, individual OON remainder = 3000-900=2100. Family remainder = 3000-900=2100. Lesser=2100. Same. Good. If family remainder lower, would limit. For claim4, individual remainder 0, family remainder 0.
Potential nuance: OOP maximum and deductible accumulators: Deductible applied counts to OOPM. Yes member cost share. Claim1 OOP credit 2220. But does the deductible portion count toward OOPM? Yes member cost share. Glossary OOPM ceiling on member cost share; deductible is member paid at allowed rate before coinsurance. Counts unless excluded. Plan says copays always credit; premiums/non-covered never. It doesn't say deductible doesn't. So yes.
Potential nuance: For out-of-network, balance billing above allowed not member responsibility? Basis says for in-network, amounts billed above allowed not member responsibility. For out-of-network? It doesn't explicitly say, but allowed amount is basis; member cost share calculated from allowed. Usually OON may balance bill, but in this harness likely member responsibility only allowed-based cost share; plan_paid plus member_responsibility equals allowed on every item that asks both. Rule family says member_responsibility plus plan_paid equals allowed amount of claim being reported, on every item that asks both. Thus no balance bill. Good.
Need decide if ending_deductible_b remains 0 or should be something due to family embedded? B had no deductible. So 0. Ending_oopm_b=260.00.
But wait: If family deductible satisfied after claim1, B's individual deductible is also "satisfied"? In embedded, individual satisfies on own; family satisfied once total family credits reach family amount, whichever comes first. Does family satisfaction waive remaining individual deductibles? Typically embedded deductible: individual deductibles are separate; family deductible met does not necessarily satisfy individual deductibles? Actually in embedded family deductible, thejson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 8,486 tokens
We need answer JSON only. Need solve claims adjudication with plan rules. Need be careful. User asks report components for Claim 4 and ending accumulators. Need likely output keys: member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount, ending_deductible_a, ending_oopm_a, ending_deductible_b, ending_oopm_b, ending_family_deductible, ending_family_oopm. Need parse accumulators meaning? "FAMILY ACCUMULATORS as of moment before Claim 1: A deductible 900 OOP 900; B 0; family total deductible 900 OOP 900". Need update with claims. Need determine ending accumulators probably amounts accumulated year-to-date? The labels deductible and out-of-pocket likely YTD credits (amount applied toward deductible/OOPM), not remaining. Need infer from wording: Accumulator running YTD total. Initial A deductible 900 means A has satisfied 900 of deductible, remaining 600 in-network? But out-of-network threshold individual 3000 measured against single member deductible balance. Need careful: Plan says in-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is threshold measured when service OON. So one balance of deductible credits, thresholds: in-network individual 1500, OON individual 3000. Family embedded: family in-network 3000, OON? It only gives out-of-network individual deductible 3000; no family OON? Maybe not specified. Need apply? For OON services, member deductible balance measured against OON individual threshold 3000. Family deductible also? It says family deductible in-network 3000 embedded. It doesn't state OON family deductible. Maybe OON deductible only individual? We must use document. Need calculate claims order.
Need understand embedded structure: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Under family rules: A member's own accumulator and family accumulator both move on every claim that generates cost share. Under embedded structure a member's deductible is satisfied by lesser of their individual remainder and family remainder. But OON thresholds complicate.
We need adjudicate claim 1-4 to get claim 4 components and ending accumulators. Need likely only report claim 4 components, but accumulators after all claims. Let's reason thoroughly.
Plan:
- Plan year 2026.
- Deductible Individual in-network 1500. Family in-network 3000. Embedded.
- Out-of-network individual 3000. In-network and OON deductible credits accumulate to SINGLE member deductible balance. The amount above is threshold measured when service OON.
- OOPM: Individual in-network 6000, family in-network 12000, individual OON 12000. Once member reaches OOPM plan pays 100% allowed for covered services remainder. Does OON OOPM separate? It says individual OON 12000. OOP credits? Copays always credit OOPM. Deductible coinsurance likely credit OOPM? Usually yes. But for OON? Need likely OON cost share counts toward OON OOPM? But there is single? Document: OOPM individual in-network 6000, family in-network 12000, individual OON 12000. It does not say in-network and OOP separate accumulators? It says accumulator running YTD total of deductible or OOPM. Initial accumulators have one OOP per member. Maybe OOP accumulator is total cost share counting toward whichever OOPM? Need maybe separate? But output only ending_oopm_a/b single. Could be total OOP credits; thresholds depend on network? Hmm.
Member cost share:
- coinsurance after deductible in-network 20/80; OON 40/60.
- Copays etc not relevant except none claims are office/ER etc. Claims are procedures/imaging/diagnostic, no copay likely. Copays do not credit deductible, always credit OOPM.
- Preventive none.
- Basis: member cost share from allowed amount.
Need adjudicate:
Initial before Claim1:
A deductible credits = 900, OOP credits = 900. B=0. Family deductible credits=900, family OOP=900.
Need know if these credits are in-network or combined? It says single member deductible balance for in-network and OON. Initial A deductible 900 likely total credits. A remaining in-network deductible = 1500-900=600. Remaining OON deductible = 3000-900=2100. Family deductible remaining in-network = 3000-900=2100. For embedded, A individual remainder 600 (IN) /? OON? family remainder 2100. B individual IN remainder 1500, OON 3000.
Need process Claim1: A OON specialist procedure, allowed 2400. No copay. Deductible applies? OON individual deductible threshold 3000, balance 900, remaining 2100. Allowed 2400. Deductible_applied = min(allowed, remaining deductible for this service) = min(2400,2100)=2100. Then remaining allowed after deductible = 300. OON coinsurance 40% member = 120, plan 60% = 180. Member responsibility = 2100+120=2220; plan_paid=180. Does deductible credits increase by 2100. A deductible credits become 3000 (900+2100). But in-network threshold? A's single balance 3000, so A in-network deductible satisfied too (>=1500). Family deductible credits? Does OON claim credit family deductible? The family deductible is in-network 3000? The plan says family deductible in-network 3000, embedded. It doesn't explicitly say OON family deductible. Under family accumulator both move on every claim that generates cost share? Rule says "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." This family accumulator maybe family deductible total includes all deductible credits? Initial family total 900 from A. If OON deductible credits accumulate to single member balance, likely family total also credits. So family deductible credits become 900+2100=3000. Family OOP credits increase by member responsibility? OOPM credits: likely member cost share counts toward OOPM. For OON claim, A OOP credits maybe 2220? Initial 900 => 3120. Family OOP credits? Usually family OOPM total includes member cost share; initial 900 -> 3120. But OON vs in-network OOPM threshold? A OOP credits 3120; A OON OOPM threshold 12000, in-network OOPM 6000. Need maybe OON cost share counts only to OON OOPM? But single accumulator? If single accumulator, threshold depends on service? Could be weird. But output likely wants total OOP credits. Need decide.
Claim2: B IN outpatient imaging allowed 1300. Before claim2:
A deductible balance 3000. B 0. Family deductible credits 3000? If yes family deductible satisfied. But embedded family deductible amount 3000. For B, individual deductible remainder in-network =1500; family remainder = 0 if family satisfied? Under embedded, once family deductible satisfied, plan pays for all members? Text: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." If family satisfied, no more deductible for any member? Usually yes: after family deductible met, all members' deductible satisfied. The harness rule: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." If family remainder is 0, deductible satisfied by 0? Hmm "satisfied by lesser of individual remainder and family remainder" maybe means amount of deductible that can be applied? Need interpret. If family remainder 0, no more deductible can be applied, because family deductible already satisfied. For B claim, B individual remainder 1500, family remainder 0, so deductible applied = 0? But in embedded plans, if family deductible met, B's deductible is considered met; coinsurance applies. So yes no deductible.
But wait: family deductible only in-network 3000. Claim1 was OON, deductible credits to single balance. Does OON deductible credit family in-network deductible? The plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." This suggests each member has one deductible credit balance. Family total likely sum of member balances? If A balance reached 3000 from OON, family total 3000, so family in-network deductible met. But is that intended? Could be yes. But there might be separate network-specific deductibles: OON individual deductible 3000, in-network individual 1500, but credits combined. So if A has 3000 credits, in-network deductible definitely met. Family total 3000, family met. Thus Claim2 B no deductible, 20% coinsurance: member 260, plan 1040. Deductible_applied 0, copay 0, coinsurance 260. B OOP credits 260. Family OOP +260. Deductible credits unchanged? B deductible credits remain 0? Or if family satisfied, does B's individual accumulator get deemed satisfied but not credits? The accumulator is running total of deductible paid, not status. B no deductible applied, so B deductible balance stays 0. Family deductible stays 3000. OOP B=260, family OOP=3120+260=3380? Wait A OOP after claim1 3120, family OOP same 3120. +260 => 3380.
But possible alternative: OON claim's deductible applied 2100 but family deductible maybe not met? If family deductible only in-network, OON credits maybe don't count toward family in-network deductible? But "single member deductible balance" and family accumulator? Need infer from initial family total 900: A had deductible 900 and family total 900. If prior claims maybe in-network. We need use family total. The harness family rule says both family accumulator move on every claim that generates cost share. So yes OON deductible applied moves family deductible. So family deductible after claim1 3000. Good.
Claim3: A IN follow-up procedure allowed 1800. Before claim3:
A deductible balance 3000; A OOP 3120. B deductible 0, OOP 260. Family ded 3000, OOP 3380.
A in-network deductible already satisfied (balance >=1500), family satisfied. Coinsurance 20% of allowed = 360 member, plan 1440. Deductible applied 0. A OOP +360 = 3480. Family OOP +360 = 3740. A deductible unchanged 3000, family unchanged. Is A OOPM in-network threshold 6000; not met. If total OOP credits 3480.
Claim4: A OON diagnostic study allowed 1600. Need before claim4: A deductible balance 3000, A OOP 3480. A OON deductible threshold 3000 satisfied. OON coinsurance applies 40%. No deductible. Member = 40% *1600 = 640. Plan = 960. Deductible_applied 0, copay 0, coinsurance 640. A OOP +640 = 4120. Family OOP +640 = 4380. Deductible unchanged 3000 (A and family). B unchanged ded 0, OOP 260. Need check if OOPM met? A OOP 4120 < in-network 6000 and OON 12000; no. Family OOP 4380 < 12000.
So likely output: member_responsibility 640.00, plan_paid 960.00, deductible_applied 0.00, copay_amount 0.00, coinsurance_amount 640.00, ending_deductible_a 3000.00, ending_oopm_a 4120.00, ending_deductible_b 0.00, ending_oopm_b 260.00, ending_family_deductible 3000.00, ending_family_oopm 4380.00.
But must ensure no subtlety with OOPM accumulator: initial OOP A 900. Claim1 OON member responsibility 2220. Does all 2220 count toward OOPM? Deductible and coinsurance generally count. But OON OOPM separate 12000; maybe in-network OOPM 6000 only counts in-network cost share; OON cost share counts toward OON OOPM 12000. If accumulators are single, but thresholds differ by network. However output asks ending_oopm_a as a number; maybe it's total out-of-pocket accumulated (all networks). The initial A OOP 900 probably includes previous in-network? If we add OON 2220, it's 3120. If separate, ending_oopm_a maybe in-network OOP? But no, they gave single out-of-pocket accumulator. Need likely total. But maybe for OON claim, cost share does not credit in-network OOPM but credits OON OOPM; if ending_oopm_a is single? Could be balance for "out-of-pocket maximum" maybe combined? Plan says OOPM individual in-network 6000, family in-network 12000, individual out-of-network 12000. It doesn't mention separate accumulator, but real plans often have network-specific accumulators. Harness initial "out-of-pocket" single suggests one accumulator per member. Could be for in-network only? But then OON cost share wouldn't update? Need examine ground rules: "Accumulator: the running year-to-date total of a member's deductible or OOPM." Not network-specific. "A member's own accumulator and the family accumulator both move on every claim that generates cost share." That implies all cost share moves OOPM accumulator. "Once a member reaches the out-of-pocket maximum the plan pays 100%..." Which OOPM? If service OON threshold 12000, IN 6000. A single accumulator can be measured against threshold based on network. So yes all cost share credits. Good.
But need verify Claim1 calculation under embedded and single deductible with family. There may be family deductible remainder 2100 and A OON individual remainder 2100. Deductible applied = lesser of allowed, individual OON remainder, family remainder? Family remainder in-network? If family total 900, family in-network remainder 2100. A OON individual remainder 2100. Same. Deductible 2100. Good.
Could there be an OON family deductible threshold? Not given. If OON family not given, maybe not relevant. Family deductible only in-network; OON services use member individual OON deductible. But family embedded could limit? "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." For OON claim, individual remainder measured against OON threshold (2100). Family remainder measured against family deductible? In-network family remainder 2100. So same. If family remainder had been smaller than individual OON remainder, deductible applied limited by family? Example if family remaining 100, individual OON remaining 2100, under embedded, would deductible applied be 100? Because family deductible satisfied after 100 and then all deductible satisfied? But for OON service, does family in-network deductible satisfaction waive OON individual deductible? Hmm, if family in-network deductible met, does member's OON deductible also met? The plan says single balance measured against OON threshold. If family met because total credits 3000, A balance 3000, so OON individual also met. But if family met via other members but A balance <3000, does A's OON deductible remain until A balance reaches 3000? The document: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." This implies for OON service, member must have balance >=3000 to satisfy OON deductible, regardless family? But embedded family may also satisfy individual deductible? Need parse: "Structure EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." For in-network. For OON individual deductible 3000. It does not say family OON deductible. If family in-network met before A OON individual threshold, would A's OON services still subject to OON deductible until A's balance 3000? Real plans often OON deductible separate individual, maybe family integrated? But harness rule says under embedded a member's deductible is satisfied by lesser of individual remainder and family remainder. Could be for any deductible. But family remainder based on family deductible amount 3000 (in-network). If family met, family remainder 0, so no deductible? That would make OON individual threshold irrelevant for members once family met by others. But plan says OON threshold measured against single member balance. Need reconcile.
For our case family met simultaneously with A OON individual threshold because A balance reached 3000. So no issue for claim4. Claim2 might be affected if family met by A OON credits. If OON credits don't count family or family doesn't waive B's deductible, Claim2 would have deductible applied. Need examine likely intended. They intentionally gave OON claim allowed 2400 with remaining OON deductible 2100, making A OON deductible met and family deductible met (from 900 to 3000) exactly. Then Claim2 B in-network likely coinsurance only. This seems intended. If they intended OON not count to family, Claim2 B would apply deductible 1300 (or 1500 min), then claim3 etc. Let's explore alternative to ensure.
Alternative 1: OON deductible credits accumulate to member single balance but family deductible only in-network credits? Initial family total 900 likely from A in-network. Claim1 OON deductible applied 2100 to A's OON balance, but family deductible maybe not updated? But harness says family accumulator moves on every claim generating cost share. It doesn't distinguish network. So likely moves.
Alternative 2: OOPM accumulators network-specific. If OON cost share doesn't count to in-network OOPM, ending_oopm maybe? But output single. Hmm.
Need ensure "ending_deductible_a" means accumulator total or remaining? Initial table says "deductible 900.00" for A. Could be amount applied YTD, because they call accumulators. If it were remaining deductible, A would have remaining 900? But plan deductible 1500. They say A deductible 900 out-of-pocket 900. Usually accumulator reported as amount accumulated, not remaining. Also family total deductible 900. If remaining, family remaining would 2100? But they label family total 900 not 2100. So definitely credits. Ending deductible A 3000 after OON threshold, not 0. Good.
But note in-network individual deductible 1500; if ending_deductible_a is single balance, after claim1 3000. If they expect deductible accumulator capped at in-network deductible? The phrase "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." So balance can exceed 1500 up to 3000. So 3000.
Need compute all claims exactly with rounding. Allowed amounts whole, percentages produce whole: 300*0.4=120; 1300*0.2=260; 1800*0.2=360; 1600*0.4=640. All .00.
Need maybe claim1 member responsibility could be 2220, plan paid 180. But not output except affects OOP. OOP A initial 900+2220=3120. Claim2 +260=3380. Claim3 +360=3740? Wait earlier I had after Claim3 A OOP 3480? Let's recalc: A OOP initial 900. Claim1 A member resp 2220 -> A OOP 3120. Claim2 B not A. Claim3 A member resp 360 -> A OOP 3480. Yes family OOP after Claim1 3120; Claim2 +260=3380; Claim3 +360=3740. Then Claim4 +640: A OOP 4120, family 4380. B OOP 260. Good.
Double-check family OOP initial 900 equals A OOP. Claim1 family OOP +2220 = 3120. Claim2 +260 = 3380. Claim3 +360 = 3740. Claim4 +640 = 4380. Good.
Need consider if deductible_applied for claim4 could be nonzero due to OON deductible separate not satisfied? A balance 3000 after Claim1. OON individual deductible 3000, satisfied. So 0.
Need consider if OOPM reached for A? A OOP 4120; if OON claim4 cost share counts toward in-network OOPM? If single accumulator and in-network threshold 6000, not reached. If OON threshold 12000, not reached. No change.
Need consider if B's deductible ending should be 1500 deemed satisfied? Accumulator is actual deductible applied, not status. But maybe when family deductible satisfied, each member's individual deductible accumulator is updated to individual deductible amount? In some adjudication, embedded individual deductible status met but credits? The phrase "A member's own accumulator and the family accumulator both move on every claijson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
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},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100GPT-5.6 Terra · OpenAI3.9s · 373 out | 6.3s · 421 out | 8.1s · 561 out
json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "4120.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3000.00",
"ending_family_oopm": "4380.00"
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": "960.00",
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4380.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "4120.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3000.00",
"ending_family_oopm": "4380.00"
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": "960.00",
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4380.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 410 tokens
**Calculating deductible thresholds**
I need to figure out the out-of-network (OON) individual deductible, which is $3,000, starting with $900. When processing the first claim allowed at $2,400, that leaves a deductible balance of $2,100. From this, there are coinsurance calculations that lead to a responsibility of $2,220. There’s also an out-of-pocket (OOP) threshold of $12,000 that seems to be accumulating as I go through claims.
For family overall, I need to clarify whether the deductible credits add up properly!
**Analyzing claim deductions**
For Claim 3, A's individual deductible balance is $3,000, which surpasses the in-network limit of $1,500. The family deductible has been met, with coinsurance leading to costs of $360, making A's OOP $3,480 and family OOP $3,740.
For Claim 4, the OON deductible is reached, resulting in a coinsurance of 40%, leading to $640 with plan costs of $960. This bumps the OOP to $4,120 for A and $4,380 for the family.
I need to clarify the outputs and check if individual thresholds have been accurately met according to the rules!json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "4120.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3000.00",
"ending_family_oopm": "4380.00"
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": "960.00",
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4380.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100GLM-5.3 Flash · Z.ai26.8s · 2,904 out | 78.2s · 3,552 out | 70.5s · 3,403 out
Reasoning · 2,453 tokens
Let me work through this carefully.
Plan: Bluebonnet PPO 1500, embedded deductible structure.
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00
- Out-of-network individual deductible: 3000.00
Key nuance: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So there is a single deductible accumulator per member. When a service is in-network, the threshold applied is the individual in-network deductible (1500.00). When a service is out-of-network, the threshold applied is the out-of-network individual deductible (3000.00). The single balance is compared against the applicable threshold.
Starting accumulators (before Claim 1):
- A: deductible 900.00, OOP 900.00
- B: deductible 0.00, OOP 0.00
- Family total: deductible 900.00, OOP 900.00
Embedded structure: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
Harness rule: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
So for each claim generating deductible credit, the deductible applied = min(member's individual remainder for that network, family remainder).
Hmm, but there's the single balance vs. network thresholds complication. Let's think.
Family deductible is 3000.00 (in-network figure). Family total deductible credits currently 900.00. Family remainder = 3000 - 900 = 2100.00.
Claim 1 — 2026-05-05 — A, out-of-network specialist procedure. Allowed 2400.00. OON coinsurance 40% member / 60% plan. No copay for OON specialist procedure (copays listed are in-network typically; the plan lists copays without network qualifiers, but out-of-network claims typically don't have copays; the plan document lists "Member cost share: Coinsurance after deductible, out-of-network 40%/60%". For out-of-network, the cost share is deductible + coinsurance. The copay schedule (PCP 30, specialist 60, urgent care 75, ER 400) — these are presumably in-network copays. The claim is "Out-of-network specialist procedure" — a procedure, not an office visit, so no copay anyway.
OON individual deductible threshold for A: 3000.00. A's single deductible balance: 900.00. Remainder to OON threshold: 3000 - 900 = 2100.00.
Family remainder: family deductible 3000, family credits 900, remainder 2100.00.
Deductible applied = min(A's remainder to OON threshold 2100, family remainder 2100, allowed 2400) = 2100.00.
Wait — the harness rule says "a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." With the single-balance rule, A's remainder against the OON threshold is 2100.00. Family remainder 2100.00. So deductible applied = 2100.00. Remaining allowed = 2400 - 2100 = 300.00, subject to 40% coinsurance = 120.00 member, 180.00 plan.
Member responsibility Claim 1 = 2100 + 120 = 2220.00. Plan paid = 180.00.
Update accumulators:
- A deductible: 900 + 2100 = 3000.00. A OOP: 900 + 2220 = 3120.00.
- Family deductible: 900 + 2100 = 3000.00. Family OOP: 900 + 2220 = 3120.00.
Note: family deductible now fully satisfied (3000). Also A's single balance is 3000, which satisfies both the in-network individual threshold (1500) and OON threshold (3000). So A has no deductible remainder for either network going forward.
Claim 2 — 2026-05-21 — B, in-network outpatient imaging. Allowed 1300.00. No copay listed for imaging (not an office visit, not urgent care, not ER, not pharmacy). So deductible then 20% coinsurance.
A's individual threshold in-network: 1500. B's balance 0, remainder 1500. Family remainder: family deductible 3000 - family credits 3000 = 0.00.
Under embedded: deductible applied = min(1500, 0) = 0.00. So B pays 20% coinsurance on full 1300 = 260.00 member, plan 1040.00.
Update:
- B deductible: 0 + 0 = 0.00. B OOP: 0 + 260 = 260.00.
- Family deductible stays 3000.00. Family OOP: 3120 + 260 = 3380.00.
Claim 3 — 2026-06-14 — A, in-network follow-up procedure. Allowed 1800.00. In-network coinsurance 20%. No copay (procedure). A's deductible balance 3000 ≥ 1500, satisfied. Family deductible satisfied. So deductible applied 0. Coinsurance 20% of 1800 = 360.00 member, plan 1440.00.
Update:
- A OOP: 3120 + 360 = 3480.00. A deductible stays 3000.
- Family OOP: 3380 + 360 = 3740.00.
Claim 4 — 2026-07-08 — A, out-of-network diagnostic study. Allowed 1600.00. OON coinsurance 40%. A's deductible: single balance 3000, OON threshold 3000 → satisfied. Family deductible satisfied. So deductible applied 0.00. Coinsurance 40% of 1600 = 640.00 member, plan 960.00.
Member responsibility Claim 4 = 640.00. Plan paid = 960.00. deductible_applied = 0.00. copay_amount = 0.00. coinsurance_amount = 640.00.
Update:
- A OOP: 3480 + 640 = 4120.00. A deductible 3000.
- B: deductible 0.00, OOP 260.00.
- Family OOP: 3740 + 640 = 4380.00. Family deductible 3000.00.
Wait — check the OOPM thresholds. Individual in-network OOPM 6000, individual OON OOPM 12000. A's OOP is 4120, below both. Family OOPM 12000; family OOP 4380, fine. No OOPM caps triggered.
Hmm, but wait — there's a subtlety about whether family OOP tracks similarly. The plan lists family OOPM 12000 in-network, and individual OON OOPM 12000. There's no family OON OOPM listed. Family total OOP: 4380.00. Fine.
Also check: does the family deductible being "satisfied" after Claim 1 hold? Family credits 900 + 2100 = 3000 = family amount. Yes. Also note under embedded, once family deductible met, no member owes deductible.
Let me double-check Claim 1's deductible applied. A's remainder to OON individual threshold: the plan says the single balance is measured against the OON threshold (3000) when the service is OON. A's balance 900 → remainder 2100. Family remainder 2100. Allowed 2400. Deductible applied = min(2100, 2100, 2400) = 2100.00. Yes.
Coinsurance on remaining 300 at 40% = 120.00. Total member 2220.00, plan 180.00. Check: 2220 + 180 = 2400 ✓.
Claim 2: B deductible applied 0 because family deductible fully met. Member 260 (20% of 1300), plan 1040. Sum 1300 ✓.
Claim 3: member 360, plan 1440. Sum 1800 ✓.
Claim 4: member 640, plan 960. Sum 1600 ✓.
Ending accumulators:
- A deductible: 3000.00; A OOP: 4120.00
- B deductible: 0.00; B OOP: 260.00
- Family deductible: 3000.00; Family OOP: 4380.00
Wait — should B's ending deductible be 0.00? Yes, B never paid any deductible because family was satisfied after Claim 1.
One more consideration: does the "lesser of individual remainder and family remainder" rule for embedded apply with the OON threshold? For Claim 1, individual remainder against OON threshold = 2100, family remainder = 2100 → 2100. If instead we had used the in-network threshold (1500) for A's individual remainder, we'd get min(600? no — A's remainder against in-network threshold 1500 - 900 = 600)... Hmm. That would give deductible applied 600. But the plan explicitly says the threshold the balance is measured against for an OON service is the OON amount (3000). The service is OON, so threshold 3000, remainder 2100. That's the correct reading. The harness rule about "lesser of individual remainder and family remainder" is about embedded structure — both are 2100 here anyway.
Actually wait, let me re-read: "Embedded deductible: an individual deductible inside a family deductible; the individual amount can be satisfied on its own." And the plan: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
For Claim 1: A's credits go to both A's individual balance and the family total. Applied 2100 → A balance 3000 (satisfies OON individual 3000, and also in-network 1500), family total 3000 (satisfies family 3000). Consistent.
Alternative interpretation some might use: individual remainder = 1500 - 900 = 600 (in-network individual), so deductible applied = min(600, family remainder 2100) = 600, then coinsurance on 1800 at 40% = 720, member total 1320. But that contradicts the plan's explicit statement that for OON services the balance is measured against the OON threshold (3000). The plan document governs. So 2100 is right.
Hmm, but there's genuine ambiguity: does "the amount above is the threshold that balance is measured against when the service is out-of-network" refer to the out-of-network individual deductible of 3000? Yes: "Out-of-network (individual) 3000.00" then "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Clear.
So Claim 4 components:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
Ending accumulators:
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
Let me double check family OOP arithmetic: 900 (start) + 2220 (C1) + 260 (C2) + 360 (C3) + 640 (C4) = 900+2220=3120; +260=3380; +360=3740; +640=4380. ✓
A OOP: 900 + 2220 + 360 + 640 = 4120. ✓ B OOP: 260. ✓
Family deductible: 900 + 2100 = 3000. ✓ A deductible: 900 + 2100 = 3000. B: 0.
Everything checks. Output single fenced JSON block with exactly the required keys.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 3,400 tokens
Let me work through this carefully.
Plan document: Bluebonnet PPO 1500.
- Individual deductible in-network: 1500.00
- Family deductible in-network: 3000.00
- Structure: EMBEDDED — individual satisfies individual deductible on their own; family deductible also satisfied once total family credits reach family amount, whichever comes first.
- Out-of-network individual deductible: 3000.00
- In-network and OON deductible credits accumulate to a SINGLE member deductible balance. The amount above (3000.00) is the threshold that balance is measured against when the service is out-of-network.
- OOPM: individual in-network 6000.00; family 12000.00; individual OON 12000.00.
- Coinsurance after deductible: IN 20% member / 80% plan; OON 40% member / 60% plan.
- Copays do NOT credit deductible; copays always credit OOPM.
- Member cost share from allowed amount.
Family accumulators before Claim 1:
- A: deductible 900.00, OOP 900.00
- B: deductible 0.00, OOP 0.00
- Family: deductible 900.00, OOP 900.00
Hmm, interesting: family deductible total is 900.00 which equals A's individual. So the "family total" here seems to be the sum of member credits (A=900, B=0, total 900). OK.
Wait — but note the plan says deductible structure is embedded. The individual in-network deductible is 1500, but the OON individual deductible is 3000. The single member deductible balance is measured against 3000 when the service is out-of-network, and against 1500 when in-network (implied).
Hmm, so A's balance is 900.00. For an OON service, threshold is 3000.00, so A needs 2100 more to satisfy OON deductible. For in-network services, threshold 1500, so A needs 600 more.
For B, balance 0. In-network threshold 1500; OON threshold 3000.
Family deductible 3000 (in-network family). Family total deductible credits: 900.
Now, how does OOPM work? Individual in-network OOPM 6000; individual OON OOPM 12000. Family 12000. The plan says "Once a member reaches the out-of-pocket maximum the plan pays 100%..." Presumably similar single balance logic but the task doesn't specify explicitly like it did for deductible. The OON individual OOPM is 12000, in-network 6000. Probably same single-balance logic: balance measured against 6000 for in-network services, 12000 for OON.
Claims:
Claim 1 — A, OON specialist procedure. Allowed 2400.00.
- OON: deductible threshold for A is 3000.00; A's balance 900.00 → remaining 2100.00. Embedded rule: member's deductible satisfied by lesser of individual remainder and family remainder? The family rules say: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Family remainder: family deductible is 3000 (in-network family amount). Family credits 900 → family remainder 2100. Hmm, but what's the family threshold for OON? The plan only gives family deductible 3000 (in-network). Actually the plan lists "Family (in-network) 3000.00" and doesn't list an OON family deductible. Hmm.
Actually the task family rules say: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
For Claim 1 (A, OON): individual remainder = 3000 - 900 = 2100. Family remainder: family deductible 3000 - family credits 900 = 2100. Lesser = 2100. So deductible applied = 2100.00. Remaining allowed after deductible = 2400 - 2100 = 300. Coinsurance OON 40% member → 120.00 member, 180.00 plan.
Wait, but does the member hit the deductible? After applying 2100, A's balance = 3000. A's individual deductible (OON threshold 3000) satisfied. Family credits = 900 + 2100 = 3000 → family deductible satisfied too.
OOP for A: 900 + 2100 + 120 = 3120.00. Copay: none for specialist procedure (copays listed are office visits etc.; this is a procedure, no copay). So copay_amount = 0.00.
Plan paid Claim 1: 2400 - 2100 - 120 = 180.00.
Hmm wait, member_responsibility + plan_paid = allowed: 2220 + 180 = 2400. Member responsibility = deductible applied + copay + coinsurance = 2100 + 0 + 120 = 2220.
Claim 2 — B, in-network outpatient imaging. Allowed 1300.00.
- B's deductible balance 0. In-network threshold 1500. Individual remainder 1500. Family remainder: family credits now 3000 (after claim 1) → family remainder 0. Under embedded rule, member's deductible satisfied by lesser of individual remainder and family remainder → 0. So deductible applied = 0.00.
Since family deductible is satisfied (family credits reached 3000), and it's embedded... The plan document: "the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." So B owes no deductible; goes straight to coinsurance.
Coinsurance in-network 20% member: 1300 × 0.20 = 260.00 member; plan pays 1040.00.
B's OOP: 0 + 260 = 260.00. Deductible applied 0.00. Copay 0.00.
Family OOP: 3120 + 260 = 3380.00.
Claim 3 — A, in-network follow-up procedure. Allowed 1800.00.
- A's deductible balance now 3000.00 (satisfied against OON threshold 3000). But for in-network services, threshold is 1500. A's balance 3000 ≥ 1500, so A's deductible is satisfied for in-network purposes. Deductible applied = 0.00.
Hmm, wait. Here's a subtlety: A's single balance is 3000. For in-network, threshold 1500. Balance 3000 exceeds 1500, so satisfied. Yes, deductible applied 0.
Coinsurance 20%: 1800 × 0.20 = 360.00 member; plan 1440.00.
A's OOP: 3120 + 360 = 3480.00. Check against OOPM: individual in-network OOPM 6000; A's OOP balance 3480 < 6000. Fine. Also OON OOPM 12000; irrelevant.
Family OOP: 3380 + 360 = 3740.00.
Claim 4 — A, OON diagnostic study. Allowed 1600.00.
- A's deductible balance 3000. OON threshold 3000 → satisfied. Deductible applied 0.00.
- Coinsurance OON 40%: 1600 × 0.40 = 640.00 member; plan 60% = 960.00.
- A's OOP: 3480 + 640 = 4120.00. Under OON OOPM 12000 → not reached. Under in-network OOPM 6000 — but this is an OON claim; the plan says individual OON OOPM is 12000. Single balance? The document doesn't explicitly say OOPM credits combine networks the way deductible credits do. Hmm.
The deductible section explicitly says: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." The OOPM section doesn't have such language. But typical design: OOPM is a single accumulator too. The thresholds differ (6000 IN, 12000 OON). Hmm, actually that's a bit unusual—usually OOPM OON is higher. Here individual IN OOPM 6000, OON OOPM 12000.
For this question, it doesn't matter much: A's OOP after claim 4 = 4120.00, below 6000 anyway. So no OOPM issue.
Ending accumulators:
- A deductible: 3000.00 (900 + 2100 + 0 + 0 + 0 = 3000).
Wait — hmm, actually let me reconsider. Should A's deductible credits be capped at 3000 for the OON threshold? A's balance was 900; claim 1 applied 2100 → 3000. That equals the OON threshold. Good.
But wait, is there an alternative reading: the deductible applied for an OON claim is limited by the individual OON deductible threshold (3000) measured against the single balance. Yes, that's what I did.
- B deductible: 0.00 (claim 2 applied 0).
- Family deductible: total family credits = 3000.00. Family threshold 3000 → satisfied.
Hmm, but should family credits for OON claims count toward the family (in-network) deductible of 3000? The plan only lists a family in-network deductible of 3000. Claim 1's 2100 credit — A's individual OON deductible threshold is 3000, and A's credits went to 3000. The family credits: does the OON credit count toward the family 3000?
The task's family rules: "A member's own accumulator and the family accumulator both move on every claim that generates cost share." So family deductible accumulator moves with claim 1's deductible applied. Family credits: 900 + 2100 = 3000. Family threshold 3000 → satisfied.
That's consistent with the embedded rule: A's deductible applied = min(individual remainder 2100, family remainder 2100) = 2100. Both hit 3000 simultaneously. Nice and clean — the numbers were designed to line up exactly (900 + 2100 = 3000).
- A OOPM: 900 + 2220 (claim1) ... let me recompute: Claim 1 OOP charge = deductible 2100 + coinsurance 120 = 2220. A OOP: 900 → 3120. Claim 3: +360 → 3480. Claim 4: +640 → 4120. So ending_oopm_a = 4120.00.
- B OOPM: 260.00.
- Family OOPM: 900 + 2220 + 260 + 360 + 640 = 4380.00.
Check: family OOP = A + B = 4120 + 260 = 4380. Yes.
Claim 4 components:
- member_responsibility = 640.00
- plan_paid = 960.00
- deductible_applied = 0.00
- copay_amount = 0.00
- coinsurance_amount = 640.00
Check: 640 + 960 = 1600 = allowed. Good.
Ending accumulators:
- ending_deductible_a = 3000.00
- ending_oopm_a = 4120.00
- ending_deductible_b = 0.00
- ending_oopm_b = 260.00
- ending_family_deductible = 3000.00
- ending_family_oopm = 4380.00
Let me double-check Claim 1's deductible application. A's individual OON deductible threshold: 3000. Balance 900 → remainder 2100. Family remainder: family threshold 3000, credits 900 → 2100. min = 2100. Allowed 2400. Deductible applied 2100. Remaining 300 subject to OON coinsurance 40% → member 120, plan 180.
One question: could the deductible applied be capped at the allowed amount? 2100 < 2400, so fine.
Alternative interpretation: maybe some would argue the OON deductible applied should be min(remainder, allowed) — yes 2100.
Claim 2: B in-network. Family deductible satisfied after claim 1 (credits 3000 = family 3000). Embedded: B's individual deductible satisfied by lesser of individual remainder (1500) and family remainder (0) = 0. So B pays 0 deductible, straight to coinsurance. Deductible applied 0.00. Coinsurance 20% of 1300 = 260. Plan 1040.
Hmm — one nuance: is B's own deductible balance credited anything? No, deductible applied is 0.
Claim 3: A in-network, allowed 1800. A's balance 3000 ≥ in-network threshold 1500 → satisfied. Coinsurance 20% = 360, plan 1440. Deductible 0.
Claim 4: A OON, allowed 1600. Balance 3000 ≥ OON threshold 3000 → satisfied. Coinsurance 40% = 640, plan 960.
All good. Also check OOPM caps: A's OOP 4120 < 6000 (IN threshold) — no cap. Family OOP 4380 < 12000.
One more consideration on Claim 1: the copay. "Specialist office visit 60.00 copay" — but Claim 1 is an "Out-of-network specialist procedure," not an office visit. No copay applies. Also OON services: copays listed are plan-level; typically copays are in-network only, but regardless, procedure ≠ office visit. copay_amount = 0.00.
Claim 4 is a "diagnostic study" OON — no copay. 0.00.
Also, should I consider whether copays credit OOPM — none here.
Now output keys:
member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount,
ending_deductible_a, ending_oopm_a, ending_deductible_b, ending_oopm_b, ending_family_deductible, ending_family_oopm.
All numbers two decimals. Just the JSON block, no extra keys.
Values:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 0.00
- ending_oopm_b: 260.00
- ending_family_deductible: 3000.00
- ending_family_oopm: 4380.00
JSON formatting: numbers as numbers with two decimals — JSON numbers like 640.00 render as 640.0 if parsed, but the instruction says report as plain number with two decimal places. I'll write them as 640.00 in the JSON text (valid JSON allows trailing zeros in decimals? JSON grammar: number = int frac? ; frac can be "00". Yes, 640.00 is valid JSON). I'll write with two decimals.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 3,251 tokens
Let me work through this carefully.
Plan: Bluebonnet PPO 1500. Embedded deductible structure. In-network individual deductible 1500, family 3000. Out-of-network individual deductible 3000. Key wrinkle: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So each member has ONE deductible accumulator. When the service is in-network, the threshold is 1500 (individual). When out-of-network, the threshold is 3000 (individual). Credits count to the single balance.
Similarly for OOPM: Individual in-network 6000, out-of-network 12000. Presumably a single OOPM accumulator too? The plan document lists "Individual (out-of-network) 12000.00" under OOPM. It doesn't explicitly say OOPM credits accumulate to a single balance, but the deductible explicitly says that. For OOPM, hmm. The document says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." The threshold would depend on network of the service presumably. Let's assume single OOPM balance as well, with threshold depending on network of service (6000 in-network, 12000 out-of-network). Actually, let me re-read: "Out-of-pocket maximum: Individual (in-network) 6000.00, Family (in-network) 12000.00, Individual (out-of-network) 12000.00". It doesn't say whether OOPM is combined or separate. In real plans, often OOPM is combined or separate by network. The deductible explicitly says single balance; OOPM doesn't say. But the harness's ground rules say where the document doesn't settle, indicate... but the output format here doesn't have an uncertainty field. Let me think about whether it matters numerically.
Starting accumulators:
- A: deductible 900.00, OOP 900.00
- B: deductible 0.00, OOP 0.00
- Family: deductible 900.00, OOP 900.00
Claim 1 — A, out-of-network specialist procedure, allowed 2400.00. No copay mentioned (specialist office visit copay is 60, but this is a "specialist procedure," not an office visit — so no copay; it's subject to deductible and coinsurance). Out-of-network: deductible threshold for A's single balance measured against 3000 (individual OON). A's deductible balance is 900.00.
But embedded: "a member's deductible is satisfied by the lesser of their individual remainder and the family remainder" — family deductible is 3000 (family in-network 3000; what's family out-of-network? The doc lists Family (in-network) 3000.00 only. Hmm. Family total deductible is 900. Under embedded, family remainder = 3000 - 900 = 2100. Individual remainder for A (OON) = 3000 - 900 = 2100. Lesser is 2100. So deductible applied = min(2400, 2100, 2100) = 2100. Coinsurance on remainder: 2400 - 2100 = 300, at 40% member / 60% plan (out-of-network). Member coinsurance = 120.00. Plan pays 60% of 300 = 180.00.
Wait — but there's a subtlety: under embedded, family deductible is 3000 total. A's credits go toward both. After Claim 1: A deductible = 900 + 2100 = 3000. Family = 3000. Both A's OON individual threshold (3000) and family (3000) reached.
Hmm, but wait — is A's in-network deductible also satisfied? A's single balance is 3000, which meets the in-network threshold 1500 and OON threshold 3000. Yes, A's balance 3000 ≥ 1500, so A is past in-network deductible too, and exactly at OON threshold.
Family deductible = 3000 → satisfied.
OOP for A after claim 1: deductible applied 2100 + coinsurance 120 = 2220 credited to OOP. A OOP = 900 + 2220 = 3120.00. Threshold for OON individual OOPM = 12000. Not reached. Family OOP = 900 + 2220 = 3120.
Claim 1 amounts: member_responsibility = 2100 + 120 = 2220.00; plan_paid = 180.00. Check: 2220 + 180 = 2400 ✓.
Claim 2 — B, in-network outpatient imaging, allowed 1300. No copay listed for imaging. Subject to deductible/coinsurance. B's deductible balance 0. In-network threshold 1500. Family deductible: 3000 reached by A already? Family total deductible after claim 1 = 3000. So family deductible is satisfied. Under embedded, "the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Family credits = 3000, so family deductible satisfied. Does that mean B pays no deductible? Under embedded rules: each member satisfies their own individual deductible on their own. Family deductible satisfied doesn't exempt B from their individual deductible under a standard embedded structure... Actually wait. Under a typical embedded deductible, once the family deductible is met, no member owes deductible anymore. Hmm, actually no — that's the aggregate structure. Under embedded: individual deductible can be satisfied on its own; the family deductible is higher. Once the family deductible is met (by combined credits), all members are done with deductibles. Yes — in a standard embedded plan, the family deductible is the total that must be met before the plan pays for anyone without deductible; but each individual only needs to meet their individual deductible for the plan to pay for them. Once the family deductible is satisfied, everyone is treated as having met their deductible.
Hmm, but this harness's rule: "Embedded deductible: an individual deductible inside a family deductible; the individual amount can be satisfied on its own." And the plan doc: "EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
So for B on Claim 2: B's individual remainder = 1500 - 0 = 1500. Family remainder = 3000 - 3000 = 0. The harness rule in TASK FAMILY: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." So deductible applied = min(1300, 1500, 0) = 0. So B pays no deductible; coinsurance 20% on full 1300 = 260 member, plan 80% = 1040.
Hmm wait, that gives member_responsibility = 260, plan_paid = 1040. Check sum = 1300 ✓.
Hmm, but is that right? "a member's deductible is satisfied by the lesser of their individual remainder and the family remainder" — this describes how much deductible the member's claim applies: the deductible applied on a claim is limited by both the member's individual remainder and the family remainder. So with family remainder 0, deductible applied = 0, and the rest goes to coinsurance. That's the standard embedded behavior once family deductible is met.
Wait, but let me double check the family remainder after Claim 1. Family deductible credits: A had 900, adds 2100 → 3000. Yes, family remainder 0.
Hmm, but actually there's a subtlety about the embedded structure and the "whichever comes first" phrasing: family deductible satisfied once total family credits reach 3000. That happened at Claim 1. So yes.
But hold on — should I reconsider? Some embedded structures: once family deductible met, all members' deductibles are waived. The harness rule explicitly: "a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." So B's deductible applied on claim 2 = min(1500, 0) = 0. Then coinsurance applies to the whole allowed amount. OK.
Actually wait, let me reconsider. Does "deductible applied" min with family remainder mean the member's cost-share deductible portion? Yes. So B: deductible_applied 0.00, coinsurance on 1300 at 20% = 260.00.
OOP: B OOP = 0 + 0 + 260 = 260. Threshold in-network individual 6000. Family OOP = 3120 + 260 = 3380. Family OOP threshold in-network 12000; not reached.
Claim 2: member_responsibility 260.00, plan_paid 1040.00.
Claim 3 — A, in-network follow-up procedure, allowed 1800. A's deductible balance: 3000 (single balance). In-network threshold 1500 → satisfied. Family deductible satisfied. So deductible applied = 0. Coinsurance 20%: member 360, plan 1440. Sum 1800 ✓.
A OOP: 3120 + 360 = 3480. Family OOP: 3380 + 360 = 3740.
Claim 3: member_responsibility 360.00, plan_paid 1440.00, deductible_applied 0.00, copay 0.00, coinsurance 360.00.
Claim 4 — A, out-of-network diagnostic study, allowed 1600. A's deductible balance 3000; OON threshold 3000 → satisfied (balance ≥ threshold). Family deductible satisfied. Deductible applied 0. Coinsurance OON 40%: member 640, plan 960. Sum 1600 ✓.
OOP check: A OOP before claim 4 = 3480. OON individual OOPM threshold 12000. 3480 + 640 = 4120 < 12000. Family OOP = 3740 + 640 = 4380 < 12000. So no OOPM cap.
Claim 4: member_responsibility 640.00, plan_paid 960.00, deductible_applied 0.00, copay_amount 0.00, coinsurance_amount 640.00.
Ending accumulators:
- A deductible: 3000.00 (900 + 2100 + 0 + 0 + 0)
- A OOP: 3480 + 640 = 4120.00
- B deductible: 0.00
- B OOP: 260.00
- Family deductible: 3000.00
- Family OOP: 3380 + 640 = 4380.00
Check family OOP: 900 + 2220 + 260 + 360 + 640 = 4380 ✓. Family deductible: 900 + 2100 = 3000 ✓.
Now, one thing to double-check: Claim 1 deductible applied 2100 — the lesser of individual remainder (OON threshold 3000 − 900 = 2100) and family remainder (3000 − 900 = 2100). Both are 2100, so 2100. Good.
But wait — should the family remainder be measured against the family OON deductible? The doc only lists "Family (in-network) 3000.00" and doesn't list a family OON deductible. The family deductible is 3000. Fine.
Another check on Claim 1: is there any OOPM consideration? A OOP after = 3120, below any threshold. Fine.
Also check: does copay apply anywhere? Claim 1 is a "specialist procedure" OON — the specialist office visit copay (60) applies to office visits; this is a procedure, and OON anyway; no copay lines for OON. Claims 2–4 are procedures/imaging/studies — no copay. So copay_amount 0.00 for claim 4.
Now the "single member deductible balance" rule: I applied the OON threshold (3000) for Claim 1 against A's existing 900 balance (which was presumably built in-network). Yes: "The amount above is the threshold that balance is measured against when the service is out-of-network." So the 900 counts, remainder 2100. Good.
For Claim 4, A's balance 3000 meets OON threshold 3000 exactly → satisfied. Good.
One more consideration on Claim 2: Could someone argue B's deductible should be applied because embedded individual deductible? The harness rule explicitly says lesser of individual remainder and family remainder. Family remainder = 0 after Claim 1. So 0. I'm confident.
Also should Claim 2's deductible applied be min(1300, 1500, 0) = 0 → coinsurance on full 1300. Yes.
Now what about whether the OOPM accumulates copays and deductible — yes, "Copays always credit the out-of-pocket maximum" and deductible amounts count toward OOPM (standard). The doc doesn't explicitly say deductible credits OOPM, but the harness glossary: OOPM is "the ceiling on member cost share" — member cost share includes deductible and coinsurance. So yes.
Ending values:
- ending_deductible_a = 3000.00
- ending_oopm_a = 4120.00
- ending_deductible_b = 0.00
- ending_oopm_b = 260.00
- ending_family_deductible = 3000.00
- ending_family_oopm = 4380.00
Claim 4 components:
- member_responsibility = 640.00
- plan_paid = 960.00
- deductible_applied = 0.00
- copay_amount = 0.00
- coinsurance_amount = 640.00
The keys asked: member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount, ending_deductible_a, ending_oopm_a, ending_deductible_b, ending_oopm_b, ending_family_deductible, ending_family_oopm.
Should I include explanations? The output contract says exactly one fenced JSON block, keys given. No extra keys. So just the JSON with those 11 keys, numbers as plain two-decimal.
Format numbers with two decimals as strings or numbers? "Report every dollar amount as a plain number with two decimal places" — JSON numbers: 640.00 in JSON is fine as 640.0 or 640.00? JSON number 640.00 is valid (trailing zeros allowed in JSON grammar? Actually JSON allows 640.00 — yes, digits after decimal point, so 640.00 is valid JSON). I'll emit numbers like 640.00. Grader likely parses numerically. Use 0.00 for zeros.
Final JSON.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Hunyuan 4 · Tencent245.1s · 15,896 out | 186.5s · 11,180 out | 199.3s · 11,971 out
Reasoning · 15,740 tokens
We need answer with JSON code block only. Need compute adjudication for claims 1-4 sequentially, given accumulators before claim 1. Plan Bluebonnet PPO 1500. Need report components for Claim 4 and ending accumulators for members A and B and family.
Let's parse carefully.
Plan document:
Year 2026.
Deductible:
- Individual in-network: 1500.00
- Family in-network: 3000.00
- Structure EMBEDDED: individual satisfies individual deductible on own; family deductible also satisfied once total family credits reach family amount, whichever comes first.
- Out-of-network (individual): 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
Interpretation: There is a single member deductible balance, with different thresholds depending on network of service: in-network services measure against individual in-network threshold 1500 (and family 3000?), out-of-network services measure against out-of-network individual threshold 3000 (and maybe family? Need parse: "Out-of-network (individual) ................ 3000.00". Is there a family out-of-network deductible? It only lists Family (in-network) 3000.00. It says "Family (in-network) ........................ 3000.00". Then "Out-of-network (individual) ........ 3000.00". "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Wait maybe this means: member has one deductible balance. The threshold for that balance depends on whether service is in or out: if service in-network, the balance is measured against individual in-network (1500) and family in-network (3000). If service out-of-network, the SINGLE member deductible balance is measured against out-of-network individual threshold (3000). But what about family out-of-network? It didn't specify a family out-of-network. It says Family (in-network) 3000.00. "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." The "amount above" refers to "Out-of-network (individual) ................ 3000.00"? Or "Family (in-network) 3000.00"? Let's read exactly:
Deductible
Individual (in-network) ................ 1500.00
Family (in-network) .................... 3000.00
Structure .............................. EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
Out-of-network (individual) ............ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
Hmm "The amount above is the threshold that balance is measured against when the service is out-of-network." Actually "the amount above" could refer to the "Out-of-network (individual)" amount 3000.00. But "SINGLE member deductible balance" means you don't have separate in-network vs out-of-network balances; you have one balance per member that accumulates from both in-network and out-of-network cost share (deductible credits). When a service is in-network, you compare that single balance to the in-network thresholds: individual 1500/family 3000. When a service is out-of-network, you compare that same single balance to the out-of-network threshold, which is 3000 individual (and maybe family? Not listed; maybe family also out-of-network? But family in-network 3000, not out-of-network; since out-of-network individual is 3000 and structure embedded maybe family out-of-network? Not given). But the family total deductible accumulator? The family accumulator under embedded structure: "the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." The family amount given is Family (in-network) 3000.00. But there is also single balance and out-of-network threshold.
Maybe simpler: The plan has separate deductible thresholds: In-network: individual 1500, family 3000. Out-of-network: individual 3000 (maybe no family out-of-network, but because single balance and embedded, family out-of-network? The family threshold when measuring out-of-network might be? Wait "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Actually "Family (in-network) .................... 3000.00" is above both Individual (in-network) and Out-of-network (individual). The sentence after Out-of-network (individual) says: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." This sentence is placed after Out-of-network (individual). "The amount above" could refer to the immediately preceding amount: Out-of-network (individual) = 3000.00. But then it says balance measured against when service is out-of-network. That makes sense: when service is OON, you measure the single balance against 3000 (individual OON). But what about family? It says "Structure EMBEDDED... family deductible also satisfied once total family credits reach the family amount". The family amount is 3000. Under embedded, for in-network, the family amount is 3000. Since out-of-network individual threshold is also 3000, maybe family out-of-network threshold is not defined; maybe all deductible credits (including OON) also count toward the family in-network amount? Wait the sentence says In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. That is about member balance, not family. Family credits: family total deductible is sum of members' deductible credits? The family accumulator is separate: family total deductible 900 before claim 1 equals A's 900 + B's 0. So family total = sum of member balances? Yes, family total deductible = sum of members' single deductible balances? Since A 900, B 0 => family 900. So family total deductible is sum of member deductible balances. The family amount (threshold) is 3000 for in-network? But if OON services generate deductible credits, do those credits count toward satisfying the family in-network amount? The text: "Family (in-network) .................... 3000.00". And "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." It doesn't explicitly say OON deductible credits count toward the family in-network amount, but since family total is sum of member balances and member balances include OON credits, family total includes OON credits. The family deductible is satisfied once total family credits reach the family amount (3000). But does that apply to OON services? The family amount listed is in-network. There is no family out-of-network amount listed. However the OON individual is 3000, so if a member reaches 3000 OON individual, their own OON deductible is satisfied. Also because family total is sum of member balances, if family total reaches 3000, does family deductible satisfied? It says "Family (in-network) 3000.00" and structure: "family deductible is also satisfied once total family credits reach the family amount, whichever comes first." That suggests family amount is 3000 (in-network). If OON credits are part of single balance, they contribute to family total. At family total 3000, the family in-network deductible is satisfied? Wait "Family (in-network)" is the family deductible amount. Under embedded, the family deductible is satisfied once total family credits reach the family amount. If OON credits count toward that total, then once total family credits (including OON) reach 3000, the family deductible is satisfied (for in-network? or for both?). Need read: "Structure .............................. EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Usually embedded family deductible: there is a family deductible amount; each member has an individual deductible amount; when the family's combined expenses toward the family deductible reach the family amount, the family deductible is considered met for all members, regardless of individual. But here they have both individual in-network 1500 and family in-network 3000. They also have out-of-network individual 3000. No out-of-network family. The single member deductible balance means both in and out network credits go to one balance. The threshold measured against depends on service network: for in-network service, compare member balance to individual in-network 1500 and family in-network 3000. For out-of-network service, compare member balance to out-of-network individual 3000? What about family threshold for OON? Maybe there is no family OON threshold, but the family in-network 3000 still is the family amount; since OON credits accumulate to member balance and family total, when family total reaches 3000, the family deductible (in-network) is satisfied, but OON services are measured against the member's OON individual threshold of 3000? Hmm.
Let's carefully examine claims and numbers to infer intended calculation.
Initial:
A deductible 900, OOPM 900. B deductible 0, OOPM 0. Family deductible total 900, OOPM total 900.
Deductible thresholds: Individual in-network 1500. Out-of-network individual 3000. Since single balance, A's balance is 900 (from prior). Does that 900 count as in-network or unknown? It is prior to claim 1; we just know A deductible 900. It is a single member deductible balance; the composition may be from in-network or OON unknown, but threshold depends on current service network.
OOPM: Individual in-network 6000, Family in-network 12000. Individual out-of-network 12000. Wait OOPM section:
Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year.
No OOPM family out-of-network? It says Individual (out-of-network) 12000.00. There is no Family (out-of-network). But similar to deductible, in-network and out-of-network OOPM? The text: "Out-of-pocket maximum Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000." No separate OOPM for in vs out? It lists Individual (in-network), Family (in-network), Individual (out-of-network). No Family (out-of-network). Perhaps OOPM: in-network: individual 6000, family 12000. Out-of-network: individual 12000 (maybe family also? but not listed). Need interpret. The sentence "Once a member reaches the out-of-pocket maximum the plan pays 100%..." The member's OOPM: for in-network services, the individual OOPM is 6000; for out-of-network services, the individual OOPM is 12000. And family in-network OOPM is 12000. Since OOPM accumulators: A OOPM 900 initial, B 0, family 900. Are these OOPM balances single or separate? The document doesn't say OOPM credits accumulate to single balance? It only says deductible: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." It does NOT say OOPM accumulate to single balance. But the family OOPM total is sum? Initial family OOPM 900 = A 900 + B 0, so yes family total OOPM is sum of members' OOPM balances. It lists Individual (in-network) 6000 and Individual (out-of-network) 12000. Does a member have one OOPM balance or separate in/out? The initial A OOPM 900; we don't know if it's in or out. There's no statement that OOP is single balance. But for adjudication, we need know which OOPM threshold applies based on service network: if service in-network, member cost share credits to OOPM and counts toward individual in-network OOPM 6000 (and family in-network 12000). If service out-of-network, member cost share credits to OOPM and counts toward individual out-of-network OOPM 12000? What about family out-of-network OOPM? Not listed; maybe family OOPM only in-network 12000, but since family total is sum of members' OOPM balances, OON cost share increases member OOPM balance and family total, but the family OOPM threshold? There is no family out-of-network OOPM amount; maybe the family OOPM is always 12000 regardless? Wait list: Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. There is no Family (out-of-network). Since Individual (out-of-network) is 12000, which equals Family in-network 12000. Maybe for OON, the individual OOPM is 12000 and there is no separate family OOPM; but family total OOPM accumulator exists? The family total OOPM is the sum of members, but the threshold for family is only defined for in-network as 12000. If a member is receiving OON service, we compare member OOPM balance to individual OON OOPM 12000. The family total OOPM might also be compared to? It doesn't list Family (out-of-network), so perhaps family OOPM satisfaction only matters for in-network? But the task asks ending_family_oopm, just the accumulator value, not whether max reached. We just report ending accumulator totals, not thresholds. So we don't need decide when family OOPM max triggers? Wait we do need to compute plan paid vs member responsibility. Plan pays 100% after member reaches OOPM. So we must know when member OOPM is reached, based on service network. For OON service, member reaches individual OON OOPM at 12000. If member OOPM balance hits 12000, then plan pays 100% for OON? Or does the in-network OOPM 6000 also apply? The member has one OOPM per? Let's examine typical plan: In-network and out-of-network may have separate deductibles and out-of-pocket maximums. Here they gave separate individual OOPM for in (6000) and out (12000). That implies a member has separate OOPM balances? Or a single OOPM balance with different thresholds? They explicitly for deductible said single member deductible balance. For OOPM they did NOT say single; they gave Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. This likely means: For in-network services, the member's OOPM limit is 6000 (individual) and family 12000. For out-of-network services, the member's OOPM limit is 12000 (individual); there is no family out-of-network OOPM listed, perhaps because out-of-network family OOPM is not applicable or same? Wait, they didn't list Family (out-of-network). But they did list Family (in-network) 12000. Maybe the OOPM section means:
- Individual in-network OOPM: 6000
- Family in-network OOPM: 12000
- Individual out-of-network OOPM: 12000
(And perhaps out-of-network family OOPM is not listed because not covered? But OON services are covered, just higher cost share.)
Maybe there are two separate OOPM accumulators per member: one for in-network, one for out-of-network? But initial accumulators given: "A (subscriber) deductible 900.00 out-of-pocket 900.00". It doesn't break out in vs out. It says out-of-pocket 900 (singular). If there were separate OOPM balances, they'd likely show two numbers? The task says "Family ACCUMULATORS as of the moment before Claim 1: A deductible 900.00 out-of-pocket 900.00". So each member has one deductible number and one out-of-pocket number. Family total deductible 900, out-of-pocket 900. So there is a single member deductible balance and a single member OOPM balance (one number each). The plan document says deductible in/out credits accumulate to a SINGLE member deductible balance. For OOPM, they didn't say that, but the accumulator representation has one out-of-pocket number per member. That implies there is a single OOPM balance per member as well (since they report one out-of-pocket accumulator). The thresholds for that single balance depend on network: for in-network service, measure against individual in-network OOPM 6000; for out-of-network service, measure against individual out-of-network OOPM 12000. And family total OOPM is sum of members' OOPM balances; the family in-network OOPM threshold is 12000. Is there a family out-of-network OOPM threshold? Not listed; maybe not needed because once any member's individual OON OOPM reaches 12000, that member is done; family total may reach 12000 as well (since individual OON OOPM equals family in-network OOPM). For in-network, family OOPM threshold 12000; if family total OOPM reaches 12000, does that satisfy all members' OOPM? Usually family OOPM: once family total reaches family OOPM, all members are considered to have met OOPM. The text: "Family (in-network) .................... 12000.00" under OOPM. So for in-network, family OOPM is 12000. There is no embedded description for OOPM, but typically yes.
But we must compute claim by claim.
Let's list claims:
Claim 1: 2026-05-05, A, Out-of-network specialist procedure. Network OON. Billed 4440, Allowed 2400.
Service: Out-of-network specialist procedure. Is this a specialist office visit? It says "specialist procedure". Copays: Specialist office visit 60 copay. But this is a procedure, and it's out-of-network. The copay listed is "Specialist office visit .......................... 60.00 copay". Does an out-of-network specialist procedure have a specialist office visit copay? The service is "Out-of-network specialist procedure". It is not necessarily an office visit; it's a procedure. The copay applies to office visit. The allowed amount 2400, billed 4440. Since OON, member responsibility includes balance billing? Wait Basis of payment: "Member cost share is calculated from the ALLOWED amount. Amounts billed above the allowed amount are not the member's responsibility for in-network services." It says "for in-network services." For out-of-network, amounts billed above allowed amount ARE the member's responsibility (balance billing) typically, but they didn't explicitly state OON balance billing. Actually they only say: Member cost share calculated from allowed amount. Amounts above allowed not member responsibility for in-network services. This implies for out-of-network, amounts above allowed ARE member responsibility (balance billing). But the task asks for member_responsibility and plan_paid. member_responsibility plus plan_paid equals the allowed amount of the claim being reported, on every item that asks for both. Wait the rule: "member_responsibility plus plan_paid equals the allowed amount of the claim being reported, on every item that asks for both." This is crucial! It says member_responsibility + plan_paid = allowed amount. That means we do NOT add balance-billed amounts above allowed to member_responsibility for these reported components? But it says "equals the allowed amount of the claim being reported". So for Claim 4, we compute member_responsibility and plan_paid such that sum = allowed amount (1600). Thus member_responsibility is only the member's cost share on the allowed amount (deductible, coinsurance, copay), NOT balance billing above allowed. Even for OON, we ignore billed above allowed for these fields? The rule says on every item that asks for both, MR + plan_paid = allowed amount. So yes, we only consider allowed amount 1600; plan_paid is plan payment toward allowed; member_responsibility is member cost share toward allowed (including deductible/coinsurance/copay). Balance billing (billed 2960 - allowed 1600 = 1360) is not included in member_responsibility? Wait but for OON, the member is responsible for the difference between billed and aljson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 11,025 tokens
We need adjudicate claims sequentially, update accumulators. Plan: Bluebonnet PPO 1500. Embedded deductible: individual in-network 1500; family in-network 3000. Out-of-network individual 3000 (deductible credits accumulate to SINGLE member deductible balance, threshold 3000 when out-of-network? Let's parse deductible section carefully.)
Plan Document:
Deductible
Individual (in-network) ................ 1500.00
Family (in-network) .................... 3000.00
Structure .............................. EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
Out-of-network (individual) ............ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
Interpretation: There is a single member deductible balance (combined in/out). If service is in-network, the individual deductible threshold is 1500, family threshold 3000 (embedded). If service is out-of-network, the deductible threshold measured is 3000 (individual out-of-network) and presumably family OON? It doesn't specify family out-of-network deductible amount. It says Out-of-network (individual) 3000.00. Then "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." So when claim is out-of-network, we measure the member's single deductible balance against 3000 (the out-of-network individual threshold), not 1500. For family? Since single member balance, family overall? It says only out-of-network individual 3000. There is no OON family amount listed. But family deductible in-network 3000. Since in/out credits accumulate to a single member deductible balance, and family deductible? Need to see how family deductible applies to OON services. The family total deductible is shown starting 900. Family total likely also single combined? The document says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." It doesn't explicitly say family deductible balance is separate or combined. The accumulators given: Family total deductible 900.00 (which equals A deductible 900 + B 0). So family deductible balance is sum of member deductible balances? Since each member has own deductible; family total is sum? Under embedded family, family deductible is also satisfied once total family credits reach family amount. So we track family total deductible = sum of members' deductible applied? The given family total deductible 900 = A 900 + B 0. It likely is sum of member deductible balances. For out-of-network services, does the family threshold become 6000? No, only individual OON threshold is 3000. The family in-network is 3000. But since credits accumulate to a single member deductible balance, family total deductible is total of member balances. For family satisfaction, "family deductible is also satisfied once total family credits reach the family amount". Which family amount? It lists Family (in-network) 3000.00. There is no separate OON family amount. So family threshold is 3000 regardless? But if OON individual threshold is 3000, and family is 3000, then for a family with two members each with single balance, if one member reaches 3000, that member's individual OON deductible met, and family total reaches 3000 (assuming other 0) so family deductible also met. The family satisfaction rule: "family deductible is also satisfied once total family credits reach the family amount, whichever comes first." So family is satisfied when family total deductible credits reach 3000 (the family in-network amount). It doesn't say OON family amount. So after family total hits 3000, family deductible satisfied. But each member's own deductible may still need to meet their individual threshold (in-network 1500 or OON 3000) before plan pays for that member? Let's parse embedded structure: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." This means for a given member's claim, the deductible that applies to that member is the individual amount (either 1500 IN or 3000 OON) OR if family total has reached 3000, then deductible is considered satisfied for everyone? Wait: "whichever comes first" means either the individual meets their individual deductible, or the family total meets the family deductible; whichever occurs first triggers that the deductible is satisfied (for the family). In standard embedded deductible, each family member has an individual deductible embedded within family deductible. The family deductible is met when the sum of all family members' expenses applied to deductible reaches the family amount, or when an individual meets their individual deductible, that individual is considered to have met their deductible (and their claims begin coinsurance). Actually standard: With embedded deductible, each individual has an individual deductible amount; once an individual meets their individual deductible, that individual is no longer subject to deductible (for the rest of year). Also, once the total family out-of-pocket (or deductible) amounts paid by all members reach the family deductible amount, then no member has to pay deductible for rest of year. The document: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." This suggests: For any claim, the member's deductible liability is the remainder of the individual deductible (or family deductible?) Actually "an individual satisfies the individual deductible on their own" means if a member's own deductible accum reaches the individual threshold (1500 IN or 3000 OON), that member has satisfied their individual deductible. Separately, the family deductible is satisfied once total family credits reach family amount (3000 IN?) Then whichever comes first: if the family total hits 3000 before the individual hits their individual threshold, then the deductible is satisfied for the family (all members). If the individual hits their own threshold first, that individual is done with deductible. The phrase "whichever comes first" typically: In an embedded family deductible, no individual will pay more than the individual deductible amount; and once the family deductible amount is met by combined expenses, the deductible is considered met for everyone. So for a specific member's claim, we compute deductible applied as the amount needed to satisfy either that member's individual deductible remainder OR the family deductible remainder, whichever is smaller? Wait: The member's accumulator instructions in the task family: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Let's re-read the harness family rules: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." This is crucial! It says member's deductible is satisfied by the lesser of their individual remainder and the family remainder. That means for a given member, the amount of deductible that can be applied on a claim is the minimum of (individual deductible remaining for that member) and (family deductible remaining)? Wait "satisfied by the lesser of their individual remainder and the family remainder." Let's parse: A member's deductible is satisfied (i.e., the amount that fulfills the deductible for that member on the claim?) by the lesser of:
- their individual remainder: how much more that member needs to pay to meet their individual deductible threshold.
- the family remainder: how much more the family needs to pay (total) to meet the family deductible threshold.
Since under embedded, once family total reaches family amount, everyone is considered to have met deductible; and a member can't be required to pay more than their individual amount. On a given claim, the deductible amount applied for the member is the lesser of the member's individual remaining deductible and the family remaining deductible. Because if family remainder is smaller, the family will hit the family cap with a smaller amount, satisfying the family; if individual remainder is smaller, the member hits individual cap. Then the deductible applied cannot exceed either remainder. This aligns with standard embedded calculation: For a family, each individual's claims go to deductible until either the individual meets the individual deductible, or the family meets the family deductible, whichever comes first. For a specific claim, the amount of the claim (allowed) that is applied to deductible is the smaller of (1) the individual's remaining individual deductible (i.e., individual threshold - individual accum) and (2) the family's remaining family deductible (family threshold - family accum). But need also consider that if service is out-of-network, the individual threshold is 3000, not 1500. The family threshold? The family deductible amount is 3000 (in-network). There is no OON family amount specified. The document: "Family (in-network) .................... 3000.00" Only. Out-of-network (individual) 3000.00. For OON service, the threshold for the member's individual remainder is 3000 (out-of-network individual). For family remainder, do we use family (in-network) 3000? The family deductible is 3000. The family total deductible accumulator is 900 initially. The family remainder is 3000 - 900 = 2100 (since family threshold 3000). But wait: if OON individual threshold is 3000, and family threshold is 3000, then family remainder 2100 is less than A's individual OON remainder? Let's compute A's individual OON remainder: A's single member deductible balance is 900 (from prior). Since A hasn't met any individual threshold. For OON service, A's individual threshold is 3000. So A's individual remainder = 3000 - 900 = 2100. Interesting: It's also 2100. So lesser of 2100 and family remainder 2100 = 2100. So on Claim 1 OON, deductible applied could be 2100, which would bring A's member balance from 900 to 3000 (met OON individual) and family total from 900 to 3000 (family met). Let's verify.
But hold on: A's single member deductible balance starts at 900. That 900 was from prior (presumably in-network? Doesn't matter, it's a single balance). For in-network services, A's individual threshold is 1500. So A's individual remainder for an in-network claim is 1500 - 900 = 600. For out-of-network, the threshold is 3000, so remainder is 3000 - 900 = 2100. The family remainder for deductible: family threshold is 3000 (in-network family). Family total deductible accum is 900. So family remainder = 2100. Under embedded, a member's deductible is satisfied by the lesser of their individual remainder and the family remainder. So for an in-network claim for A, deductible applied would be min(individual remainder 600, family remainder 2100) = 600. That would bring A's member balance to 1500 (individual IN met) and family total to 1500; family remainder becomes 1500. For an out-of-network claim for A, deductible applied = min(2100, 2100) = 2100, bringing A balance to 3000 and family total to 3000 (family met). After family total hits 3000, family remainder = 0, so any further claims from any member have deductible applied = min(individual remainder, 0) = 0 (deductible satisfied for family). But wait, if A meets OON individual at 3000, A's individual OON satisfied. For B (spouse), B's individual IN threshold is 1500; B's balance is 0. Family total is 3000 after claim 1, so family met. Then B's future in-network claims have deductible applied = min(B individual remainder 1500-0=1500, family remainder 0) = 0. So B pays no deductible; instead coinsurance? Actually once family deductible met, plan pays benefits subject to coinsurance (and copays?) until OOPM. Let's confirm.
Now OOPM: Individual (in-network) 6000. Family (in-network) 12000. Individual (out-of-network) 12000. There's no family OON OOPM listed? There's Individual (out-of-network) 12000. The family OOPM is 12000 (in-network). Wait OOPM section:
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
So family OOPM is 12000 (presumably in-network? But OOP max family is 12000; individual OON 12000). There is no separate family OON OOPM. The task asks ending_family_oopm. We need track family OOPM accumulator. Initially family total OOPM = 900. A OOPM = 900, B OOPM = 0. Family OOPM threshold? It gives Family (in-network) 12000. Is there family OON? Not specified; only Individual (out-of-network) 12000. But family OOPM is 12000, same as individual OON. Does the family OOPM apply regardless of network? The OOPM section lists Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. It doesn't say Family (out-of-network). However, "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." For a member, which OOPM? If in-network, individual IN OOPM 6000. If out-of-network, individual OON OOPM 12000. Since cost share from OON (coinsurance 40%, deductibles, copays?) counts to OOPM. The family OOPM: Family (in-network) 12000. Does family OOPM combine all members' OOP spending? Initially family total OOPM is 900 (A's 900). That equals A's OOPM. So family OOPM is sum of members' OOPM balances? Or is family OOPM a separate family accumulator that is the total of member OOP expenses? The prompt says "FAMILY ACCUMULATORS as of the moment before Claim 1: A deductible 900, OOP 900; B deductible 0, OOP 0; Family total deductible 900, OOP 900." This shows family total OOP = A OOP + B OOP = 900. So family OOPM accumulator is sum of members' OOP balances. We need track each member's OOP balance and family total OOP. But the task asks ending_family_oopm. So family OOP = sum of A OOP and B OOP? They gave ending_family_oopm key; we must compute total family OOP (sum of members?) Let's check: They ask for ending_oopm_a, ending_oopm_b, ending_family_oopm. The family total OOPM is probably A + B (since family total deductible was A+B). Yes initial family OOP 900 = A 900 + B 0. So ending_family_oopm = ending_oopm_a + ending_oopm_b. But wait, there may be a family OOPM threshold of 12000; if family total OOP reaches 12000, plan pays 100% for all? The OOPM section says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It says member reaches the OOP maximum. There is also family OOP maximum. Under typical embedded OOP, once family OOP maximum is met, all members are considered to have met OOPM. The harness family rules: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." It only explicitly mentions embedded for deductible, but OOPM has Individual and Family amounts. We need infer OOPM embedded similarly? The plan says OOPM: Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. It doesn't state embedded for OOPM, but it's an embedded deductible plan? Actually "Structure .............................. EMBEDDED" under Deductible only. OOPM doesn't have structure line, but lists Individual and Family amounts. In standard plans, OOP maximum is also embedded: no individual pays more than individual OOP max, and once family OOP max met, everyone is covered 100%. The harness says "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." It doesn't say OOPM, but by analogy we should treat OOPM similarly? Wait, the family rule: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." This sentence is specifically about deductible. For OOPM, we need compute member OOPM remainder and family OOPM remainder. On a claim, member cost share (deductible + coinsurance + copay) credits OOPM. The member responsibility (cost share) is added to member OOP accumulator and family OOP accumulator. If family OOP reaches family OOPM (12000), then plan pays 100% (presumably no further member cost share). But here ending OOPM amounts are far below 12000? Let's compute: initial A OOP 900. Claim 1 OON specialist procedure allowed 2400, member responsibility maybe deductible 2100? Wait specialist procedure out-of-network: copay? Copays listed: Specialist office visit 60 copay. But this is a "Out-of-network specialist procedure". Is it an office visit or procedure? It says "specialist procedure". The copay for Specialist office visit is 60.00 copay. Is a procedure subject to copay or deductible/coinsurance? In benefit plans, office visit copay applies to office visits (evaluation/management). A "procedure" might be subject to deductible and coinsurance, not just a specialist office visit copay. The service says "Out-of-network specialist procedure". The plan's member cost share lists: "Specialist office visit .......................... 60.00 copay". It does not list a copay for specialist procedure. Typically, a specialist office visit copay applies to the office visit; if a procedure is done, it may be subject to deductible/coinsurance. The prompt lists "Specialist office visit" not "specialist procedure". So we must not apply a copay unless it's an office visit. Claim 1 is "Out-of-network specialist procedure" — not an office visit. So no copay; subject to deductible and coinsurance. Network OON: coinsurance after deductible, out-of-network 40% member / 60% plan. Since OON, member coinsurance 40% of allowed after deductible. No copay. So Claim 1: allowed 2400. Network OON. Compute deductible applied. A member balance before claim = 900. OON individual threshold = 3000. Individual remainder = 3000 - 900 = 2100. Family deductible threshold = 3000 (Family in-network amount? but does family threshold for OON also 3000? Need decide). Family total deductible accum before = 900. Family remainder = 3000 - 900 = 2100. Lesser = 2100. So deductible applied = 2100 (cannot exceed allowed 2400). Then remaining allowed after deductible = 2400 - 2100 = 300. Coinsurance OON member 40% of 300 = 120.00. Plan pays 60% of 300 = 180. Copay = 0 (not office visit). Member responsibility = deductible 2100 + coinsurance 120 = 2220. Plan paid = 180. Check: member_responsibility + plan_paid = 2220 + 180 = 2400 allowed. Good.
After Claim 1:
A deductible balance = 900 + 2100 = 3000. (Met OON individual threshold 3000; also met? A's single balance 3000.)
Family total deductible = 900 + 2100 = 3000. Family deductible threshold 3000 reached. So family deductible satisfied. Family remainder = 0.
A OOPM balance = 900 + 2220 = 3120? Wait initial A OOPM 900. Member responsibility of 2220 credits OOPM. So A OOP = 900 + 2220 = 3120. Family OOP = 900 + 2220 = 3120. B deductible 0, OOP 0.
But need check: Does member responsibility include amounts that are not covered? Yes cost share credits OOPM. Deductible, coinsurance, copays all count to OOPM (except OON amounts above allowed? But member responsibility is only up to allowed for in-network; for out-of-network, billed 4440, allowed 2400. Member responsibilityjson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 11,814 tokens
We need to adjudicate claims in order for Bluebonnet PPO 1500 synthetic plan. Need report components for Claim 4 and ending accumulators. Required keys: member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount, ending_deductible_a, ending_oopm_a, ending_deductible_b, ending_oopm_b, ending_family_deductible, ending_family_oopm.
We need compute accumulators step-by-step. Let's restate plan details.
Plan year 2026. Amounts per plan year. Deductible: Individual in-network 1500.00, Family in-network 3000.00. Structure EMBEDDED: individual satisfies individual deductible on own; family deductible also satisfied once total family credits reach family amount, whichever comes first. Out-of-network (individual) 3000.00. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network. Important: There's a single member deductible balance for combined IN and OON? It says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Wait, need parse carefully. It says:
Deductible
Individual (in-network) ................ 1500.00
Family (in-network) .................... 3000.00
Structure EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
Out-of-network (individual) ............ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
Interpretation: For a member, there is a deductible balance that receives credits from both in-network and out-of-network services. There are thresholds: individual in-network threshold is 1500 for in-network services? Wait, "Individual (in-network) ................ 1500.00" and "Out-of-network (individual) ............ 3000.00". Then sentence: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Actually "The amount above" might refer to "Out-of-network (individual) ............ 3000.00" is the threshold that balance is measured against when the service is out-of-network. And "Individual (in-network) 1500" is threshold when service is in-network? Let's parse: They list Individual (in-network) 1500, Family (in-network) 3000, structure embedded. Then Out-of-network (individual) 3000. Then: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." That likely means: There is a single combined deductible balance per member. For in-network services, the member's deductible threshold is 1500 individual (or family embedded 3000). For out-of-network services, the threshold is 3000 individual (and presumably family out-of-network? But only individual OON listed). Since credits accumulate to a single member deductible balance, if the member has met e.g., 900 in-network, that 900 applies to the single balance. When an out-of-network service occurs, you measure that balance against the out-of-network threshold of 3000? Wait "The amount above is the threshold that balance is measured against when the service is out-of-network." The amount above is Out-of-network (individual) 3000. So for OON service, the deductible threshold is 3000 individual. But the balance already has credits from in-network and OON. Once the single balance reaches 3000, the individual OON deductible is satisfied (for OON services). For in-network services, threshold is 1500 individual. So if the balance is below 1500, in-network service applies deductible until balance reaches 1500; then coinsurance. If balance is between 1500 and 3000, in-network services are past deductible (no deductible), but OON services still have deductible until balance reaches 3000. That makes sense: separate thresholds by network but single balance. Let's adopt: member deductible balance (combined IN/OON credits). For IN service: individual IN threshold 1500 (family embedded 3000). For OON service: individual OON threshold 3000. Need also family embedded: family deductible (in-network) 3000? Actually Family (in-network) 3000. For OON, no family OON amount listed. The single member deductible balance contributes to family total deductible? The family total deductible given accumulators: Family total deductible 900 as of before Claim1. The family deductible amount (in-network) is 3000. Since family structure embedded: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." So for family in-network deductible 3000, if total family deductible credits (sum of member deductible balances? Or credits applied to family deductible?) reach 3000, family in-network deductible satisfied for all members (meaning remaining individual deductibles? Actually embedded: each member has individual deductible 1500; once a member meets 1500, that member's deductible satisfied. Also once the sum of family deductible amounts credited reaches 3000, then the family deductible is met, meaning all members' deductibles considered satisfied? Wait standard embedded deductible: family has a family deductible amount (e.g., 3000) and each individual has an embedded individual deductible (1500). The individual deductible is the max any one person pays before their coinsurance starts. The family deductible is the total amount the family pays before the plan starts paying for everyone? Let's recall: Embedded deductible: The family deductible is the total amount the family must pay before the plan pays. But each family member also has an individual deductible (embedded). No individual can pay more than the individual deductible before their coinsurance begins. The family deductible is satisfied when the sum of individual deductible payments reaches the family deductible. Once family deductible satisfied, plan pays for all. Under an embedded structure, a member's deductible is satisfied by the lesser of their individual remainder and the family remainder. The task rules say: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Wait read family rules: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." So for a claim, the deductible applied to that claim is limited by the lesser of the member's remaining individual deductible and the family's remaining deductible? Let's parse: Yes, in embedded family deductible, when a member incurs deductible, the amount credited to the member's individual deductible also counts toward the family deductible. The deductible applied for a claim cannot exceed the member's individual remaining deductible, and also cannot exceed the family remaining deductible? Actually if family remaining is less than member individual remaining, then the claim can only apply up to family remaining because once family deductible is met, the member's deductible is considered satisfied (family remainder zero), so no more deductible for anyone. Conversely, if member individual remaining is less than family remaining, the member meets their individual deductible, so deductible applied is the member's individual remaining (and that amount also reduces family). So the deductible applied on a claim is the lesser of (member's remaining individual deductible) and (family remaining deductible). But need also consider network thresholds? Because there are different individual thresholds for IN vs OON. The "individual remainder" might be measured against the threshold applicable to the service network. The plan says: "Individual (in-network) 1500", "Out-of-network (individual) 3000". Single member deductible balance. So the member's remaining individual deductible for an in-network service = max(0, 1500 - member_deductible_balance). For an out-of-network service = max(0, 3000 - member_deductible_balance). Because the single balance is measured against the threshold for the service. And the family remaining deductible? Family (in-network) 3000 is listed. There is no family out-of-network amount. The family total deductible accumulator starts 900. Family total deductible credits accumulate? The family total deductible is the sum of member deductible credits (the single balances?) Actually family total deductible before Claim1 is 900, which equals A's deductible balance 900 (since B is 0). So family total deductible is sum of member deductible balances? It says Family total deductible 900. Yes A 900 + B 0 = 900. So family deductible balance is sum of member deductible balances (credits). The family threshold (in-network) is 3000. The family remaining = max(0, 3000 - family_total_deductible). For out-of-network services, is there a family OOPM? Not listed for deductible. Only Family (in-network) 3000 deductible. But the single member balance for OON threshold 3000; family total also increases with OON deductible credits. Does family total have a 3000 cap for OON? Not specified; only Family (in-network) 3000. But family total deductible credits from OON count toward family total; however the family deductible amount is 3000 (in-network). Does an OON service's deductible credit count toward satisfying the family in-network deductible? The plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." And family total deductible is sum of member balances. The family deductible (in-network) 3000 is the family amount. Under embedded, family deductible satisfied once total family credits reach the family amount. Since total family credits include OON credits, they would count toward the 3000 family amount. I think yes, because it's a single member balance and family total is sum. There's no separate family OON deductible amount, so the 3000 family amount applies to total credits (including OON). We'll assume family remaining for any service is 3000 - family_total_deductible (since only family amount is 3000). Wait there is also out-of-network individual 3000 but no family OON. So for family embedded, the "family remainder" is against 3000 (the family deductible amount). Actually standard: Family deductible 3000 means total family deductible credits must reach 3000. It doesn't matter network. So family remaining = 3000 - family_total_credits. Once family_total reaches 3000, family deductible satisfied; all members' deductibles considered satisfied (no more deductible for any service, any network?). But the plan says "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." If family total credits reach 3000, then family deductible satisfied, so a member doesn't have to meet their individual 1500? Wait embedded: Usually the family deductible is the total the family pays before the plan pays. Under embedded, the individual deductible is embedded within the family deductible. That means: The family deductible (3000) is the total that must be paid by the family before the plan begins to pay for any family member? Actually no: In an embedded deductible, the individual deductible amount (e.g., 1500) is the max any individual pays; the family deductible (3000) is the total the family pays before the plan pays for everyone. Let's recall exactly: There are two types: aggregate and embedded. Aggregate: family deductible must be met in full before plan pays for any member. Embedded: each family member has an individual deductible (e.g., $1,500) embedded in the family deductible (e.g., $3,000). Each member must meet their own individual deductible, but no more than the individual amount. The family deductible is met when the sum of individual deductible amounts paid reaches the family deductible. Once the family deductible is met, the plan pays for all members, even those who haven't met their individual deductible? Wait that's the opposite? Let's check: Actually embedded deductible: The family deductible is the total amount the family must pay before the insurance starts paying. But each individual has an embedded individual deductible, which is the maximum amount any one individual will have to pay toward the family deductible. So under embedded, if one member incurs $1,500 (individual deductible), that member's deductible is satisfied and the plan starts paying for that member (subject to coinsurance). The $1,500 also counts toward the family $3,000 deductible. If another member then incurs $1,500, the family deductible $3,000 is met. If a third member had incurred $0, they would not have to pay any deductible because the family deductible is already met. Yes: Once the family deductible amount is reached, the deductible is considered met for everyone. So the family remaining limits further deductible: once family total credits = 3000, no more deductible for anyone. That matches rule: "a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." So for a claim, deductible applied = min(member_individual_remainder_for_network, family_remaining). Wait if member individual remainder > family remaining, then deductible applied = family remaining, because after that family is satisfied, so member's deductible is satisfied (family remainder zero). If family remaining > member individual remainder, the member meets their individual deductible, so deductible applied = member individual remainder (and member's deductible satisfied; family still remains for others). Yes.
Now OOPM: Individual in-network 6000, Family in-network 12000, Individual out-of-network 12000. Structure? It doesn't say embedded for OOPM? It says "Out-of-pocket maximum: Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It doesn't specify embedded or aggregate for OOPM. But typical: There is individual OOPM and family OOPM. It says "Once a member reaches the out-of-pocket maximum the plan pays 100%..." That suggests individual OOPM satisfaction triggers 100% payment for that member. Does family OOPM exist as aggregate? It lists Family (in-network) 12000. Also individual OON 12000. It doesn't list family OON OOPM. Since no structure specified, we need interpret from general rules? The task family rules: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." That rule specifically for deductible under embedded. For OOPM, the plan says once a member reaches the OOPM the plan pays 100%. It doesn't say embedded, but since there is a family OOPM amount 12000 (in-network), likely the OOPM also has embedded structure? Actually in many plans, OOPM also has embedded individual OOPM within family OOPM. The plan lists Individual (in-network) 6000 and Family (in-network) 12000. That's exactly 2x, typical embedded: family OOPM is 2 times individual. For out-of-network, individual OOPM 12000 (which equals family in-network 12000), but no family OON. And "Once a member reaches the out-of-pocket maximum the plan pays 100%" means individual OOPM (6000 IN or 12000 OON) satisfaction ends member cost share for that member. But there is also a family OOPM (in-network) 12000. Under embedded OOPM, once family OOPM met, plan pays 100% for all members. Need to see if OOPM uses embedded. The plan document doesn't say "Embedded" for OOPM, but the deductible section explicitly says Embedded. The OOPM section says: "Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." The phrase "Once a member reaches the out-of-pocket maximum" refers to the member reaching their individual OOPM (the member's OOPM). There is a family OOPM listed, so likely once family OOPM (12000 in-network) is reached, all members are considered to have reached OOPM. But does OOPM accumulate in a single balance for IN/OON? It says Individual (in-network) 6000 and Individual (out-of-network) 12000. There is no statement that IN and OON OOPM credits accumulate to a single member OOPM balance. It says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." That is only for deductible. For OOPM, it lists separate individual IN and individual OON amounts. It doesn't say they accumulate to a single balance. So we likely have separate OOPM balances? Need infer. The accumulators given: A deductible 900, out-of-pocket 900. Since before Claim1, A had deductible 900 and OOPM 900. That implies the 900 credited to deductible also credited to OOPM (because deductible payments count toward OOPM). So A's out-of-pocket accumulator is 900. There's no separate IN vs OON OOPM balances shown; it's a single "out-of-pocket" accumulator per member and family. The plan lists Individual (in-network) OOPM 6000 and Individual (out-of-network) OOPM 12000. That implies the threshold depends on network: for in-network services, the member's OOPM threshold is 6000 individual; for out-of-network services, the threshold is 12000 individual. But the member's OOPM accumulator (balance) is a single running total? The given accumulator is just "out-of-pocket" 900. So there is a member OOPM balance. When a service is in-network, that balance is measured against the in-network individual OOPM 6000 (and family in-network 12000). When a service is out-of-network, the balance is measured against out-of-network individual OOPM 12000. Copays always credit OOPM. Deductible and coinsurance also credit OOPM (member cost share). So the member OOPM balance accumulates all cost share (deductible, coinsurance, copays). It is a single balance, but thresholds differ by network (IN threshold 6000, OON threshold 12000). Is that correct? Yes, similar to deductible: single balance, but threshold depends on service network because different IN/OON cost sharing. For OOPM, plan says Individual (in-network) 6000, Individual (out-of-network) 12000. So for OON service, member OOPM remainder = max(0, 12000 - member_oopm_balance). For IN service, remainder = max(0, 6000 - member_oopm_balance). Also family OOPM: Family (in-network) 12000. No family OON OOPM listed. The family OOPM accumulator before Claim1 is 900. For in-network service, family OOPM remaining = 12000 - family_oopm_total. For OON service, is there a family OOPM threshold? Not listed. But family OOPM total is 12000 (in-network). Since it's the only family OOPM amount, perhaps it applies to total family OOPM credits (including OON), and once family total OOPM reaches 12000, plan pays 100% for all (for in-network? Or for OON too?). The document: "Family (in-network) ................ 12000.00". It doesn't say family out-of-network OOPM. However, "Once a member reaches the out-of-pocket maximum the plan pays 100%..." So OOPM satisfaction is pjson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Qwen3.8 Flash · Alibaba226.5s · 15,047 out | 88.3s · 8,043 out | 149.5s · 7,968 out
Reasoning · 14,860 tokens
We need answer JSON only. Need adjudicate claims with plan document. Need think carefully.
We need report components for Claim 4 and ending accumulators for every member and family. Need apply claims in order, each updates accumulators member AND family. Deductible embedded. Need understand out-of-network deductible single member balance? Plan doc:
Deductible:
Individual in-network 1500
Family in-network 3000
Structure EMBEDDED — individual satisfies individual deductible on their own; family deductible also satisfied once total family credits reach family amount, whichever comes first.
Out-of-network individual 3000
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
This is tricky. A member's single deductible balance accumulates all credits. For in-network service threshold is individual 1500. For out-of-network service threshold measured against same balance is 3000. So a member can have applied credits; if balance is 900, for IN they need 600 to satisfy IN deductible. But for OON, need 2100 more? Or if the member's individual deductible threshold is 1500 for IN and 3000 for OON measured against same balance, but embedded with family. We need adjudicate order.
Family accumulators before Claim1: A deductible 900, OOPM 900; B 0; Family total deductible 900, OOPM 900. Note A's deductible accumulator likely total credits to member deductible balance, 900 (below both 1500/3000). Family deductible total 900.
Claims:
1 A OON specialist procedure, allowed 2400. Billed 4440. OON allowed amount member cost share from allowed. Need deductible applied: For OON, individual threshold 3000 measured against member balance. A has 900, needs 2100 to reach 3000. Since family deductible? The deductible applied is lesser of individual remainder and family remainder? Rule: Under embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder. For OON individual remainder is 3000 - 900 = 2100. Family remainder for in-network? Family total is 3000, credited 900, remainder 2100. lesser = 2100. Claim allowed 2400, apply deductible 2100, remaining 300. Coinsurance OON 40% member = 120, plan 180. Copay 0. But does deductible apply only to allowed? Yes. A's member deductible balance increases by deductible applied 2100 -> 3000. Family total deductible increases 2100 -> 3000. OOPM increases member responsibility (deductible + coins) = 2220? Need check if deductible credits count toward OOPM? Plan says copays credit OOPM; deductible? In glossary: OOPM ceiling member cost share; member cost share includes deductible/coinsurance/copay. Usually all member cost share except premiums count, except out-of-network? Plan says once reaches OOPM plan pays 100% allowed for covered services. Not specify OON excluded from OON OOPM? There are OON individual OOPM 12000, IN family 12000, individual 6000. Need track? For each service, OON deductible and OON coinsurance likely count to member's OOPM? The OOPM has in-network individual/family, out-of-network individual. Family OOPM only in-network? Need understand how OON cost share affects family accumulators. The task asks ending_oopm_a and ending_oopm_b, ending_family_oopm. Since no explicit separation of OON OOPM accumulator. They provide single accumulators for deductible and out-of-pocket for each member and family. The plan doc has individual OON OOPM 12000 but not family OON. Need likely apply cost share to OOPM accumulators regardless, but if OON OOPM is separate? Hmm.
Need infer intended adjudication from "contested adjudication". They say each claim updates accumulators the next claim measured against, member and family. They only provide ending_deductible and ending_oopm. Need track all member responsibility credits. Maybe OON deductible applies to OON deductible threshold (same member balance) and counts to OOPM. Family deductible total counts all deductible credits? But family deductible is "in-network 3000" maybe out-of-network doesn't satisfy family in-network deductible? But the task rule says A member's own accumulator and family accumulator both move on every claim that generates cost share. Under embedded structure a member's deductible is satisfied by lesser of individual remainder and family remainder. So family deductible moves on OON claim. But for OON services, individual threshold 3000 and family remainder? Family in-network 3000 remainder 2100, same.
Need also OOPM: if family OOPM accumulates all cost share? They say once member reaches out-of-pocket maximum plan pays 100% covered services. There are individual OON OOPM threshold 12000. But ending_family_oopm? Could mean family in-network OOPM only? But if OON cost share included? Need analyze possible.
Let's list all claims and adjudicate stepwise under likely approach.
Starting:
A ded bal 900, OOPM 900
B ded bal 0, OOPM 0
Family ded total 900, OOPM 900
Thresholds:
A IN ded 1500, OON ded 3000; family ded 3000.
OOPM: A IN 6000, OON 12000, family IN 12000. There might not be family OON.
Need OOPM status: If any cost share would push over applicable OOPM? Need track caps. If member reaches OOPM, plan pays 100% of allowed for covered services for remainder. But OOPM is by network? If OON has separate OOPM 12000. Family only in-network OOPM 12000? The initial A has 900 OOPM. After claim1 member responsibility 2220, total 3120. Not over 6000/12000. If OON counts to family IN OOPM? family total 900 + 2220=3120.
Claim2 B in-network imaging allowed 1300. B deductible balance 0, needs 1500 IN; family ded remainder? Starting family after claim1 3000, satisfied? If family deductible is satisfied, under embedded structure does B need to satisfy own deductible? Family deductible satisfied once total family credits reach family amount whichever comes first, but individual deductible still applies. So B's deductible applies up to min(individual remainder 1500, family remainder? If family total already 3000, remainder 0. Does lesser = 0? But embedded: individual can satisfy on own; family satisfied does not waive individual deductible? Usually family deductible: once family met, plan pays before individual deductible? Wait embedded deductible means individual deductible must be met for each member before coinsurance? Actually in ACA: EPO/HSA with individual and family deductibles; benefits paid when either individual deductible for that person is met OR family deductible is met (for family plans, once family met, individual deductibles not required for members who haven't met their own). But this synthetic plan says: "EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." This can mean two ways: once family deductible satisfied, plan pays even if individual not satisfied? "whichever comes first" suggests individual deductible applies until either the individual amount reached or family amount reached total. So if family total 3000, then individual remainder can be 0. Thus B claim after family deductible is met might have no deductible, only coinsurance. But task rule: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." This explicitly says member's deductible satisfied by lesser of individual remainder and family remainder. If family remainder 0, deductible applied 0. That means B after family total reaches 3000 has no deductible, even if own 0. But wait if family deductible satisfied by A's OON credits? Under embedded, OON deductible credits accumulate to family total? If yes, then family total reached 3000 after Claim1. Claim2 B applies only coinsurance (in-network 20%) allowed 1300 -> member 260. If family not count OON to family IN deductible, then family ded total still 900 after Claim1? But task says family accumulator moves on every claim generating cost share, likely yes. Need reconcile.
Alternative: Deductible applied for each service is min(individual threshold for network - member balance, family threshold - family total). For claim2: B ind rem 1500, fam rem maybe 2100? Actually if claim1 didn't move family ded due OON? But rule says family accum moves. Let's test both.
Need also after claim1 if A's deductible balance 3000 (OON threshold met). Family total 3000. Claim2 B: min(1500,0)=0; coins 260; B OOPM 260; family OOPM 3380. Deductible balances unchanged: A3000, B0, fam3000.
Claim3 A IN follow-up allowed 1800. A member balance 3000, IN remainder 0, family remainder 0. So deductible applied 0. Coins 20%=360. A OOPM 3120+360=3480, family 3740?
Claim4 A OON allowed 1600. A member balance 3000, OON remainder 0, family remainder? If family total includes OON and IN credits =3000? But family deductible maybe in-network 3000; if OON counts, family remainder 0. Deductible 0. OON coinsurance 40%=640. A OOPM 4120, family 4380. B unchanged OOPM 260, deductible 0.
Ending: Claim4 member 640, plan 960, ded 0, copay 0, coins 640. ending ded A 3000? But if IN and OON single balance, A is 3000. ending oopm A 4120. B 0 and 260. fam ded 3000? fam oopm 4380.
But is that too straightforward? Need verify Claim1: A OON allowed 2400. If A had 900, OON deductible needs 2100; family remaining also 2100; apply 2100. Coins 40% of 300=120. Member 2220. If copays not relevant. Plan 180. A OOPM after claim1 3120. Family OOPM 3120. Family deductible 3000.
Claim2 B IN if family deductible satisfied: no ded. 20% coins=260, plan 1040. Family deductible stays 3000, B deductible stays 0. But if "lesser of individual remainder and family remainder" and family remainder is zero, yes. Does B deductible apply because individual not satisfied? The document says family deductible is also satisfied once total family credits reach family amount, whichever comes first. "whichever comes first" means yes family satisfaction can satisfy individual? For embedded in some contexts "individual deductible satisfied on their own; family deductible also satisfied once total family credits reach family amount, whichever comes first." I interpret as for cost share calculation: deductible applied to a claim = min(remaining individual deductible for that network, remaining family deductible). That's the task rule. So after family ded met, no deductible.
But maybe the family deductible is in-network only and out-of-network deductible credits do not count to family in-network deductible? The plan doc: "Out-of-network (individual) 3000. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." It doesn't say family deductible is single balance? It says Family (in-network) 3000. But task rule: each claim updates family accumulator; member's deductible satisfied by lesser of individual remainder and family remainder. It may imply family accumulator moves on every claim generating cost share, including OON. But family deductible amount is in-network. Hmm.
Need think about contest: "contested adjudication" perhaps has tricky network thresholds and OOPM. We must decide. Let's parse plan text carefully.
Deductible:
Individual (in-network) ................ 1500.00
Family (in-network) .................... 3000.00
Structure .............................. EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
Out-of-network (individual) ............ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member
deductible balance. The amount above is the threshold that balance is measured
against when the service is out-of-network.
This only mentions single member balance for individual. It doesn't explicitly mention single family balance for out-of-network. But Family (in-network) 3000. So family deductible may be in-network only. Yet the task rule says "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." This could be a generic family rule for embedded, not overriding document's family in-network only? But "both move on every claim that generates cost share" could mean all cost share accumulators (deductible, OOPM) move, including OON. But if family deductible is in-network, OON deductible credits might not move family deductible? However the family deductible accumulator supplied is just "deductible" no network. Maybe there is one family deductible balance; plan doc names family in-network amount but also says structure EMBEDDED; no family out-of-network. The task instruction likely expects family total moves with all deductible credits. Let's consider possible expected gold.
Need maybe track separate network deductibles? "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." This implies no separate IN/OON member deductible balances; just one threshold per network. For family, no OON amount, but if single family balance exists? Since the rule says family accumulator moves, likely yes, with threshold family in-network 3000. Thus OON deductible credits count to family total. If not, they would need separate family OON threshold or not move family deductible. They did not supply family OON; likely family total is common.
Now OOPM. The document:
Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year.
No family OON OOPM. But task asks ending_family_oopm (singular) and provides starting "out-of-pocket" not split. How to handle? Could be a single family OOPM accumulator that applies to both in-network? If individual OON OOPM 12000 is higher than individual IN 6000. But family OOPM is 12000. Maybe family OOPM threshold is 12000 for in-network; OON cost share maybe only counts to individual OON OOPM, not family? But task's ending_family_oopm likely is total cost share for family (could include OON). If there is a family OOPM threshold of 12000, it might cap family IN services only; but since values under thresholds, no cap issue.
Need maybe use OOPM thresholds to decide if claims capped? Claim4 member responsibility maybe not simply coins if OOPM reached? Check totals. Starting A OOPM 900. Claim1 OON cost 2220 -> 3120. If OON OOPM threshold 12000 not cap; family 12000? no. Claim2 B 260 -> B 260; A still 3120; family 3380. Claim3 A 360 -> 3480; family 3740. Claim4 A 640 -> 4120; family 4380. No cap. If a different interpretation has B deductible 1300 or 1500? Still below. If family OOPM only in-network, ending maybe includes all cost? Need know.
Need consider deductible applicability to OON coinsurance after deductible? For claim1: OON allowed 2400, deductible applied 2100. But does OON deductible apply separately from family in-network deductible? Under single member balance: A threshold for OON 3000; after claim1 A deductible balance 3000. However his in-network deductible threshold 1500 also satisfied earlier at 1500. So claim1 after OON deductible 2100? Actually if IN threshold 1500 and family in-network threshold 3000, but A's member balance for OON measured against 3000. Family threshold 3000. For claim1, applying 2100 to member balance. But would family deductible be satisfied at 3000 by OON? if yes, yes. For IN services later no deductible. If not, B claim would apply 1500 or 1300? Let's explore alternative where family deductible doesn't move with OON claim. Then:
Claim1: A OON deductible 2100 to OON, A member balance 3000; family deductible maybe stays 900? But task rule says family accumulator moves on every claim generating cost share, so probably not. But maybe "family deductible" is in-network and out-of-network deductible credits only count to member, not family. Let's test because could change claims.
Alternative A (family ded no OON credits):
After claim1: A ded 3000, family ded 900 (if not moved), OOPM family 3120? (cost share may move family OOPM). Claim2 B IN allowed 1300: B ind rem 1500, fam rem 2100 -> min 1300? Actually allowed 1300, apply deductible 1300 (B balance 1300, fam 2200). Coins 0. B member 1300. Claim3 A IN allowed 1800: A ind rem 0 (balance 3000), fam rem 800, min 0 -> no ded, coins 360. Claim4 A OON allowed1600: A OON rem 0, fam rem? if family ded is in-network and OON rem for family? Maybe family threshold for OON not defined; if family not move, perhaps A OON ded already satisfied; no ded, coins 640. End A ded 3000, oopm: A 900+2220+360+640=4120. B ded 1300, oopm 1300. family ded 2200? fam oopm 900+2220+1300+360+640=4380. Claim4 still ded 0. But ending B/ded/fam ded differ. If claim2 family deductible moved? Let's not jump.
Alternative B (family deductible moves, but only deductible credits not coins? Actually family deductible accumulator is credits to deductible, not total cost share. It moves only deductible applied, not coinsurance/copay. We already applied only ded. Good.)
Alternative C: For claim1, because A had 900 deductible credits, is in-network threshold 1500 partially satisfied, but for OON, threshold 3000 measured against single balance. Need maybe family deductible satisfied at 2100? Yes. But if claim is OON, does family in-network deductible credit? If yes. If no, claim2 B would need deductible. The question likely designed around single member balance but family total? They emphasize "member AND for the family." Maybe they expect family total moves each claim, making Claim2 no deductible. The tricky part might be OON deductible credit counts to family deductible because of embedded rule? The task family: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." This strongly suggests after Claim1 family ded remainder is zero, so Claim2 deductible 0. We'll follow.
Need decide Claim1 deductible applied perhaps should be 1500 not 2100? Wait for out-of-network specialist procedure. Individual out-of-network threshold 3000; member already has 900; remaining 2100. Family in-network 3000; remaining 2100. apply 2100. Correct. But "lesser of their individual remainder and family remainder" - individual remainder if service out-of-network? Is individual remainder maybe max(0, 3000 - 900) =2100; family remainder 2100; same. If claim allowed 2400, apply 2100. But if only in-network deductible satisfied at 1500, could family deductible? Let's see if family remainder for claim1 before claim maybe 2100; yes. If the member had only 900, but their in-network deductible remaining 600. Since service is OON, should we first apply remaining in-network deductible 600 and then out-of-network additional? The single member balance threshold is 3000 for OON; not separate. If allowed 2400, to get to 3000 need 2100. It includes the 600 that would have completed in-network. Good.
Need consider copay: OON specialist procedure not covered copay? The plan has specialist office visit copay 60. This is procedure, not office visit; likely subject to deductijson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 7,856 tokens
We need answer JSON only. Need compute claims sequentially. Must be careful. Let's parse plan.
Plan Bluebonnet PPO 1500:
- Deductible: Individual in-network 1500, family in-network 3000, embedded. Out-of-network individual 3000. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above (3000) is threshold that balance is measured against when service is out-of-network.
This wording tricky: A member's deductible balance? "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Means if service OON, the individual threshold is 3000 for that single balance? But if service IN, threshold 1500? Need understand embedded? Usually single deductible balance? It says OON deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network. For OON service, apply member OON threshold 3000 to the existing member deductible balance (which may include IN credits). For IN service, apply IN threshold 1500 to member balance? Family threshold 3000? Need decide. Also family total deductible? It lists family in-network 3000; OON? Only individual OON. Family total likely in-network family deductible? But OON claims also credit family? Need compute family accumulators. Starting family deductible 900 (A has 900 member deductible and family total 900). Need track member deductible balances, family deductible total. Also OOPM: individual in-network 6000, family in-network 12000, individual OON 12000. Copays always credit OOPM but not deductible. OON cost share: member 40% after deductible? Does member pay difference between billed and allowed? For in-network not member's responsibility. For out-of-network plan document doesn't explicitly mention balance billing, but "Allowed amount" likely member responsibility calculated from allowed? Glossary: Member cost share always calculated from allowed amount, never billed. So use allowed amount. For OON allowed 2400 etc. OON coinsurance after deductible 40% member/60% plan. What about amounts above allowed? Not member? For OON? Basis of payment says member cost share calculated from allowed; amounts billed above allowed are not member's responsibility for in-network services. It doesn't explicitly say OON, but likely also from allowed? Usually OON allowed may be plan's contracted or reasonable, member cost share from allowed. We'll assume cost share on allowed.
Need adjudicate Claim 1 A OON specialist procedure allowed 2400 billed 4440. Starting A member deductible balance? They say family accumulators as moment before Claim 1: A deductible 900.00, out-of-pocket 900.00. Family total deductible 900. For A, individual in-network deductible threshold 1500, OON threshold 3000. "SINGLE member deductible balance" measured against threshold when service OON. If A has 900 credits, OON threshold 3000 => remaining 2100 before coinsurance. Claim 1 is OON. Apply deductible 2100? But careful: member's own deductible: under embedded, member's individual remainder and family remainder. For A OON, threshold 3000; family? Need family deductible threshold? There is family in-network 3000; OON family? Plan doc says Individual (out-of-network) 3000; In-network and OON deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network. For A claim OON, deductible_applied likely min(member remaining 2100, family remaining? family threshold 3000? Starting family total 900 => family remaining 2100. So same.
Claim 1: allowed 2400. Deductible applied 2100. Remaining 300. OON coinsurance after deductible: member 40% of 300 = 120. plan paid 180. Copay 0? Specialist procedure out-of-network no copay (specialist office visit copay only office visit; procedure subject to deductible). Member responsibility 2220. Plan paid 180.
Accumulators: A member deductible balance increases by deductible applied? It credits deductible. 900+2100=3000. For IN threshold it's above? But threshold maybe not relevant until IN claim? A member deductible credits single balance. Family deductible total credits 900+2100=3000. Does family threshold met? Yes if family threshold 3000. But OON family? Maybe yes. Need careful: family deductible maybe in-network 3000. OON deductible credits accumulate to single member balance; does it count toward family deductible? Likely yes, family total. But if family threshold is in-network, OON credits may not satisfy family deductible? In real embedded OON might have separate family? But plan says single member deductible balance, family total deductible 900. Probably total across all deductible credits regardless network. Need use.
A OOPM: deductible + coinsurance count: 2220. Starting 900 => 3120. Which threshold? Individual IN 6000, OON 12000. Since A's OOPM balance maybe measured against threshold based on service network? Plan: Individual (in-network) 6000, Individual (out-of-network) 12000. Once member reaches OOPM plan pays 100 for covered services. It doesn't state single OOPM balance or network-specific thresholds. But likely each member has separate OOPM thresholds for IN and OON? Starting A OOP 900 unspecified network. Need track total member cost share? Could be one OOP accumulator, but threshold for current claim network determines if OOP max reached? The plan says individual OON 12000. So OON coinsurance/deductible count toward OON OOP? But if IN claim, threshold 6000. However starting 900 likely credits? Need infer. "All amounts are per plan year. Out-of-pocket maximum Individual (in-network) ... Individual (out-of-network) ..." It may mean separate OOP maximums by network? But no separate accumulators. Starting family accumulators: A out-of-pocket 900. We need ending OOPM_a likely total OOP credited? The key names ending_oopm_a not ending individual network. Probably report accumulated out-of-pocket cost share (not capped?), or capped? Need decide. They want ending accumulators for every member and family. Could be cumulative OOP credits, not capped. But if a member reaches OOPM, additional cost share should not accrue. In calculations, after OOPM reached plan pays 100%, no deductible/copay/coinsurance. But OOP accumulator remains at maximum? Typically OOP accumulator would not exceed maximum because no more cost share after hitting cap. But if there are separate thresholds and a claim's cost share pushes over cap, plan pays excess? Need model: if remaining to OOP less than calculated cost share, only charge remaining, then plan pays rest. Accumulator reaches max (or maybe beyond if total credits includes overage? Usually not). Need inspect claims: Claim 4 maybe after Claim 3 might push A or B OOP? Need compute.
Claim 2 B in-network outpatient imaging allowed 1300, billed 2405. Starting B deductible 0. Family deductible after claim1? Need family threshold? B IN threshold individual in-network 1500; family in-network 3000 but after claim1 family total 3000 satisfied. Embedded: Under embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder. For B, if family deductible satisfied, does B need no deductible? Rule says: member's own accumulator and family accumulator both move. Under embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder. So when family remainder = 0, member deductible obligation = 0 even if individual remaining. So B's deductible applied 0 due to family met? Need consider OON credits satisfy family deductible? Claim1 A OON deductible applied 2100. If OON deductible credits count to family deductible, family total reaches 3000; then B IN claim deductible waived? But is that right? If OON deductible threshold 3000 credits to a single member deductible balance, but family deductible maybe "Family (in-network) 3000". OON deductible may not credit family in-network? Plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." It doesn't explicitly state OON credits count toward family deductible, but family accumulator given as A 900 before claims implies family total is sum of A/B deductible credits. Usually all covered services' deductible payments accumulate to deductible, whether network? In many plans OON deductible separate or higher. Here they emphasize single member deductible balance. But family? They list family in-network; no family OON. Could be family deductible only in-network? But Claim 1 OON would credit only individual OON threshold? Hmm.
Need parse carefully: Deductible section:
Individual (in-network) 1500.00
Family (in-network) 3000.00
Structure EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
Out-of-network (individual) 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
This implies member has a single deductible balance (credits). For services, threshold depends on network: IN threshold 1500, OON threshold 3000. Family amount? It says family in-network 3000; embedded: individual satisfies individual deductible on own; family deductible is also satisfied once total family credits reach family amount, whichever comes first. Total family credits maybe member balances sum. But if OON thresholds use 3000 for individual; family threshold for OON? Since no family OON, perhaps family deductible applies to both networks? The family amount is in-network 3000; maybe credits from any network count to family. If yes, Claim1 OON with A's single balance after 2100 =3000, also family total=3000 satisfied. Then B IN no deductible.
But alternative: OON deductible does not apply family deductible? But embedded says individual and family whichever first; OON member threshold 3000. If no family OON threshold, maybe family threshold irrelevant for OON? Starting family total 900 maybe from A IN? Need apply rule: under embedded, member's deductible satisfied by lesser of individual remainder and family remainder. For Claim1 OON: individual remainder = max(0, OON threshold 3000 - member balance 900) = 2100. Family remainder = max(0, family threshold 3000 - family total 900) = 2100. Lesser=2100. So yes same. After Claim1 family total =3000, individual balance=3000.
Claim 2 B IN: B member balance 0. Individual in-network threshold 1500; individual remainder 1500. Family threshold? For IN family 3000; family total 3000; family remainder 0. Under embedded, deductible applied lesser = 0. So B pays coinsurance after deductible: 20% of 1300 = 260. plan paid 1040. Copay 0. B OOP +=260; B deductible balance unchanged? It says credits accumulate to single member deductible balance. If no deductible paid, no credit. But family total unchanged? Family already 3000. If B's deductible satisfied by family, does B have any balance? No. For future B OON? B member balance 0, but family total 3000. If OON individual threshold 3000 but family satisfied? Embedded says member's deductible satisfied by lesser of individual remainder and family remainder. Family remainder 0, so B's deductible satisfied even for OON? That seems odd: if family deductible satisfied, member doesn't need OON deductible. But plan says OON individual threshold; if family met, waived? Usually OON deductible separate, but embedded structure with single deductible credits and family? The wording: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Whichever comes first suggests if family amount met, individual need not meet own. For OON threshold? Could waive OON deductible after family IN deductible met? That might be intended but questionable. Need compute Claim3/4 under this.
Claim 3 A in-network follow-up procedure allowed 1800. Starting A member balance after Claim1 =3000. IN threshold 1500 -> individual remainder 0. Family remainder 0. deductible 0. Coinsurance 20% = 360. plan paid 1440. Copay 0. A OOP +=360 from 3120 to 3480. Family OOP? Starting family OOP 900. Claim1 +2220 =3120; Claim2 B +260 =3380; Claim3 +360=3740. Family deductible 3000.
Claim 4 A OON diagnostic study allowed 1600. Starting A member balance 3000, family total 3000. OON individual threshold 3000, individual remainder 0; family remainder 0. deductible 0. Coinsurance after deductible OON member 40% of 1600=640. plan paid 960. Copay 0. A OOP +=640 from 3480 to 4120. Family OOP +=640 ->4380.
Ending accumulators: A deductible 3000 (or perhaps if IN threshold only? member deductible balance 3000? If ending_deductible_a asks ending deductible accumulator maybe credits? likely 3000.00), A OOPM 4120. B deductible 0, B OOP 260. Family deductible 3000, family OOP 4380.
Claim4 components: member_responsibility 640, plan_paid 960, deductible_applied 0, copay 0, coinsurance 640.
But need verify if OOPM cap triggered: thresholds: Individual IN 6000, OON 12000. A OOP 4120 no. Family IN 12000 no. OK.
But wait: Copay amounts? Specialist office visit copay maybe applies if office visit. Claims are procedures/study, no copay. Outpatient imaging no copay. OK.
Now alternative models can produce different. Need deeply analyze possible pitfalls.
Potential pitfall: For out-of-network services, member cost share might be based on billed charges? But basis of payment: Allowed amount, amounts billed above allowed are not member's responsibility for in-network services. It does not say OON. Glossary says allowed. The task likely expects allowed. Use allowed.
Potential pitfall: Family deductibles and OON: Could be separate deductible accumulators? They mention single member balance, but family total? Need examine.
The phrase "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Could mean: The "above" in OON line is threshold; all deductible credits (whether in or out) go into a single member deductible balance. But for IN claims you compare to individual in-network threshold, for OON claims you compare to individual OON threshold. This yields the model used. But for family threshold? Maybe family deductible is also a single balance. But if an OON service has a higher individual deductible, does family deductible apply to OON? The family amount listed as in-network 3000. Maybe there is no family OON deductible, so OON services not governed by family deductible? However they ask family accumulators, not separate networks. Need use embedded rule: "under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." This seems explicitly tells to compare member and family remainders. Which individual remainder? The threshold for service network. Family remainder? likely family in-network threshold. Therefore yes.
Potential issue: Starting A deductible 900. Does it count against OON threshold 3000 and IN threshold 1500? Yes single balance. So Claim1 OON deductible applied 2100. If it didn't count OON (separate), Claim1 would apply full 2400 deductible then coinsurance 0? Actually 2400 under 3000 all deductible; member 2400; OOP 3300; family total 3300? But family IN threshold? no. Which is plausible? Let's see.
Need infer from wording: "Out-of-network (individual) 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
This says starting balance counts for OON threshold. So our model likely right.
Potential issue: Does Claim 1 OON deductible payment 2100 also count as family deductible? Family starting 900; threshold 3000; yes. But if family threshold is in-network only? The amount above? Hmm.
Potential issue: After Claim1 family deductible total reaches 3000. For Claim3 IN A deductible applied 0. OK.
Potential issue: B's deductible ending 0. But if family waiver, B has no deductible. OK.
Potential issue: OOPM accumulators by network? They ask ending_oopm_a, family. We need likely total member responsibility that counts toward OOPM. But if separate thresholds, could require total for IN vs OON? No key not separate. Need output total accumulated. But if separate OOPM by network and service network thresholds, how to track starting 900? It says A out-of-pocket 900, no network. Likely a single accumulator measured against threshold of claim's network? Similar to deductible. We used total accumulator; Claim4 if A total OOP 4120, but if OON threshold 12000 and IN threshold 6000 maybe both OK. If claim cost share would exceed threshold? No. Need maybe separate OOP by network? If separate, Claim1 OON costs (2220) go to OON accumulator; starting 900 maybe which? Not specified. Since only one key, output total credits. It may be OK because no cap.
Potential issue: Plan pays 100% of allowed for OON if OOP max reached? Plan doc says once member reaches OOPM, plan pays 100% of allowed for covered services. It says individual OON OOPM. But no effect.
Potential issue: Emergency room waived etc not relevant.
Potential issue: Preventive care not relevant.
Need output exactly JSON code block and nothing else. Keys:
member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount,
ending_deductible_a, ending_oopm_a (for A (subscriber))
ending_deductible_b, ending_oopm_b (for B (spouse))
ending_family_deductible, ending_family_oopm
Need values two decimals as strings? The instructions: report every dollar amount as plain number with two decimal places and no currency symbol. In JSON numbers cannot enforce trailing zeros. Usually JSON number 640.00 is invalid? JSON permits 640.00? Yes number can have fraction with trailing zero, 640.00 valid but many serializers output 640.0. To ensure two decimals, output as strings? It says plain number with two decimal places, no currency symbol. It says JSON. In JSON a number can be 640.00; textual JSON representation can include trailing zero. Is that considered valid JSON? yes, number grammar allows fraction digits after decimal; trailing zero allowed. So output numbers with two decimals e.g. 640.00. Some parsers accept. Need be consistent. They likely expect numeric values with two decimals. We can output unquoted numbers with two decimals. JSON syntax: 640.00 OK.
Need ensure member_responsibility + plan_paid = allowed claim4 = 1600.00: 640+960. OK.
Need maybe include only Claim4 components, not all claims. But also ending accumulators. OK.
Double-check all calculations:
Start:
A ded bal = 900; family ded total = 900; A OOP=900; family OOP=900.
C1: A OON allowed 2400. Individual OON threshold 3000; member ded bal 900 => remaining 2100. Family threshold 3000; family total 900 => remaining 2100. Ded applied 2100. Left 300. OON coins 40% =120. plan paid=180. member=2220. Update A ded=3000; family ded=3000. A OOP=900+2220=3120; family OOP=900+2220=3120.
C2: B IN allowed 1300. B ded bal=0; individual IN threshold 1500 -> rem1500; family rem=0; embedded deductible applied=0. Coins 20%=260; plan 1040. B OOP=260; family OOP=3380. B ded remains 0? It didn't pay deductible, but family satisfied. Should B's deductible "ending_deductible_b" maybe 0. Butjson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 7,781 tokens
We need answer JSON only. Need solve claims. Need careful. Plan Bluebonnet PPO 1500 synthetic. Family accumulators before Claim1: A ded 900, OOP 900; B ded0, OOP0; family ded900, OOP900.
Need report components for Claim4 and ending accumulators after Claim4 for A/B/family.
Need apply rules. Need decide accumulator behavior: member and family deductible. Embedded. In-network and out-of-network deductible credits accumulate to SINGLE member deductible balance. Threshold for OON when service OON? Out-of-network individual deductible 3000.00. Family in-network deductible 3000? There is only one family total deductible accumulator? The family accum shows deductible 900. Need likely credits from all claims accumulate to family deductible (same 3000 threshold? OON family? Not specified). It says Family (in-network) 3000. Structure embedded. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is threshold balance measured against when service is out-of-network. For family: family total deductible likely single accumulator threshold 3000? Need infer.
Claims:
1 A OON specialist procedure, allowed 2400.
2 B in-network outpatient imaging, allowed 1300.
3 A in-network follow-up procedure, allowed 1800.
4 A OON diagnostic study, allowed 1600.
Need copays? Procedures/imaging not listed office visit/urgent/ER/pharmacy, so no copay (unless specialist office visit copay? "Out-of-network specialist procedure" not specialist office visit, no 60 copay; diagnostic study/procedure not visit. So copay 0). Preventive? No. So deductible+coinsurance.
Important: Out-of-network basis: member cost share from allowed amount? "Member cost share is calculated from the ALLOWED amount. Amounts billed above allowed not member's responsibility for in-network services." For OON, billed above allowed likely member's balance? They ask allowed and components. Usually member responsibility only allowed-based; billed allowed excess not member's responsibility? Plan pays allowed minus member; remaining billed member balance-billed. But output keys require member_responsibility + plan_paid = allowed amount. So use allowed.
Need process in order.
Claim1: A starts deductible 900, family 900. Service OON. OON individual deductible threshold 3000. Member deductible balance = 900. Apply deductible until member OON deductible threshold 3000 (remaining 2100). Allowed 2400. deductible applied = 2100. Coinsurance after deductible 40% on remaining allowed? remaining 300. Member coins 40%=120, plan 180. OOP credits: deductible applied + coinsurance = 2220? Also copay 0. OOPM individual OON threshold 12000. Not reached. A new deductible = 900+2100=3000 (meets OON individual ded, also family? Family accum +2100=3000 meets family deductible? yes). A OOP = 900+2220=3120. Family OOP=900+2220=3120? Need family accumulators track member OOP contributions. Family total before 900. Add cost share 2220 -> 3120. B unchanged. Family deductible 3000 after claim1. Need whether family deductible threshold 3000; yes.
Claim2: B in-network imaging allowed 1300. B member deductible 0, family deductible accumulator 3000? Embedded: family deductible satisfied once total family credits reach family amount whichever comes first. After Claim1 family deductible reached 3000. What happens for B's in-network deductible? Does B still need to satisfy individual deductible even though family deductible met? Under embedded structure, if family deductible met, plan pays for any member (often individual deductible no longer required for subsequent claims once family met). But phrase: "Structure .............................. EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." That could mean for each claim deductible requirement satisfied by either individual or family deductible? "whichever comes first" means once family deductible reached, all members have deductible met? Usually yes: embedded means individual deductible satisfied separately, but once family met all satisfied. Also task family rule: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." For a new member B with individual remainder 1500 and family remainder 0, satisfied by lesser of individual remainder and family remainder (0), so no deductible. Thus Claim2 after family ded met: B has 0 deductible applied. In-network coinsurance 20% member on 1300 = 260; plan 1040. No copay. OOP credits 260. B member deductible? Does B's deductible balance stay 0? Since no cost share applied to deductible. Family deductible stays 3000 (cannot exceed threshold). OOP accumulators: B +260=260; family +260 = 3380; A unchanged 3120. Note if family deductible remains capped at 3000? yes.
Claim3: A in-network follow-up procedure allowed 1800. A member deductible: before claim3 A at 3000. Family at 3000. In-network individual deductible threshold 1500? A already over. So deductible 0. In-network coinsurance 20% on 1800 = 360. Plan 1440. OOP credits 360. OOPM? A individual in-network 6000 but OON individual 12000. He is at 3120, add 360=3480. B 260, family 3380+360=3740. Deductibles remain 3000. Note if A OOPM threshold depends on service? no.
Claim4: A OON diagnostic study allowed 1600. Before claim4: A member deductible balance 3000, OOP 3480? Wait after claim1 3120 + claim3 360 = 3480. Family OOP 3740. A OON deductible threshold 3000: satisfied. Family deductible 3000 satisfied. So deductible applied = 0. OON coinsurance after deductible: 40% member on allowed 1600 = 640. Plan paid 960. Copay? diagnostic study no copay. Need check if A OOPM out-of-network 12000? A 3480 + 640=4120. Under individual OON 12000. In-network individual OOPM 6000 irrelevant for OON? Need consider OOPM once reached plan pays 100 for covered services remainder. For OON individual threshold 12000. Not reached. Family OOP threshold in-network 12000? OON family not specified. 3740+640=4380, not reached. B unchanged 260.
But there may be nuance: OON deductible threshold for A: individual OON 3000, A already has 3000 due to Claim1. But what about family deductible? In-network and OON credits accumulate single member deductible balance; threshold when service OON. Family total before Claim1 900, Claim1 applies 2100 -> 3000. Claim2 B no deductible because family satisfied; if family not satisfied? Claim2 would apply some B deductible and family deductible until 3000? Need check if family deductible was already 3000 after Claim1, so no. But if Claim2 before family? no. Good.
However, there is potential alternative interpretation: Family deductible is separate from member? Need embedded rule. Claim1: Since A has OON deductible threshold 3000, member applied 2100. Family deductible in-network? Does out-of-network deductible credits count to family deductible threshold 3000? It says in-network and out-of-network deductible credits accumulate to a single member deductible balance. Family? likely yes. Also family total accumulator before 900, after Claim1 3000. If out-of-network family threshold is same? Not specified; likely yes.
Need produce ending accumulators for every member and family after Claim4. The keys: ending_deductible_a, ending_oopm_a, ending_deductible_b, ending_oopm_b, ending_family_deductible, ending_family_oopm. Are these individual member accumulators for in-network or actual balance? They may expect ending member deductible accumulator capped at threshold? Let's think.
Ending_deductible_a: after claim1 A reached OON deductible 3000, but his individual in-network deductible threshold is 1500. How record member deductible accumulator? Family accumulators given initially A 900. Since in-network and OON accumulate to single member deductible balance. Ending_deductible_a likely 3000.00 (cumulative credits, capped? Could be 3000 since OON threshold. But individual deductible threshold 1500; if only measuring in-network, after claim1 he exceeded. But for OON threshold, 3000. The accumulator is actual credit, not capped at 1500. For Claim4, no deductible. If they ask ending_deductible_a after all, likely 3000. But if they use deductible accumulator capped to family? Need not.
Potential issue: Family total deductible initial 900, after Claim1 3000. But family deductible maximum is 3000. Ending family deductible 3000.00. Good.
Potential OOPM accumulator for B: only Claim2 260. Does B family deductible credits? no. OOPM ending_b 260.
Need check if member_responsibility and plan_paid for Claim4: member 640, plan 960. Sum allowed 1600. deductible_applied 0, copay 0, coinsurance 640.
Need maybe include billed charges excess for OON? Required keys only these, member+plan equals allowed. Good.
But let's deeply verify all intermediate and potential thresholds. Need ensure Claim1: OON deductible applied = 2100? Allowed 2400. Before A deductible 900. OON individual ded threshold 3000. Remaining 2100. Apply 2100. Remaining 300. Coinsurance 40%=120. Total member 2220. Family deductible: before 900. Since out-of-network deductible credits accumulate? The family deductible is in-network 3000. But Claim1 OON; does it reduce OON family? There is no OON family deductible threshold. Family total after 3000. If not, then family would remain 900 until Claim2. But embedded rule says each claim updates accumulators for member AND family. Which family accumulator? It doesn't say separate OON family; likely all deductible credits count to family total. Need maybe family deductible for OON? Plan only lists Family (in-network) 3000, and individual OON 3000. Since "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." For family? It says family total; probably single family deductible balance. So Claim1 contributes to family deductible.
But another possibility: Under embedded, "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." For out-of-network, there is no OON family threshold; family credits count same as in-network? If so yes.
Claim2: B in-network imaging. Before claim2, family deductible satisfied at 3000 due to Claim1. The rule: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." If A's Claim1 moved family remainder to 0, B's deductible satisfied by lesser of 1500 and 0=0. Thus no deductible. Good. But there is nuance: individual in-network deductible threshold for B 1500; family in-network 3000. Claim1 applied 2100 OON credits. Is family deductible satisfied by OON credits? Yes? If not, Claim2 deductible applied 2100? Let's examine. Plan: "Out-of-network (individual) 3000. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." This specifically says credits accumulate to single member deductible balance, with threshold measured based on service. It doesn't explicitly state family. But the task says family accumulators. Likely family single too. In embedded, family deductible is total credits of all members. There is no separate OON family. Since OON member deductible threshold is 3000, and family in-network threshold is 3000. Claim1 credits A by 2100 -> member 3000; family total by 2100 -> 3000. Good.
What about if A's OON deductible threshold 3000, but his member accumulator after Claim1 3000 exceeds individual in-network deductible 1500. If Claim2 were A in-network, his deductible would be satisfied. Fine.
Now OOPM: Need consider family OOPM threshold 12000, individual in-network 6000, individual OON 12000. For A's Claim1 OON, OOPM? He paid 2220. The OOPM individual OON threshold 12000, not reached. Then Claim3 in-network coins 360. OOPM total 3480. Is he subject to in-network OOPM 6000 or does OON coins count to in-network OOPM? OOPM individual (in-network) 6000, individual (out-of-network) 12000. There are separate OOPM thresholds for in-network and out-of-network. But OOPM accumulators? It says Once a member reaches the out-of-pocket maximum the plan pays 100% of allowed amount for covered services for remainder. They ask ending_oopm_a likely total member OOP credits (not threshold). Do OON credits count toward in-network OOPM? In actual ACA separate OON accumulation might not count toward in-network OOPM until separate; but if they ask single ending_oopm_a likely all cost share. Need use supplied rule. They give individual in-network and out-of-network OOPM thresholds, but no statement about accumulating separately. Task family accumulators have A out-of-pocket 900 initial before claim1; likely single OOP accumulator for each member/family. It may be used to measure whichever OOPM threshold applies at claim time. If A's OOP accumulator includes OON credits, then after Claim4 =4120. If thresholds separate maybe not but ending likely total OOP accumulator. They ask ending_oopm_a not "in-network". We track cost share credits. Good.
Need maybe Claim4: If A's OOPM in-network 6000? His total OOP after claim3 is 3480; add 640 = 4120. If OON threshold 12000. Not reached. If total OOP exceeded 6000? no. If initial A OOP 900 was prior in-network? Doesn't matter.
Let's double-check arithmetic:
Start A ded 900 OOP 900; B 0 0; Family ded 900 OOP 900.
Claim1 allowed 2400. OON. A remaining ded to 3000: 2100. Ded applied 2100. Postded allowed 300. 40% member=120. Plan=60% 300=180. Member total 2220. OOP increment 2220. A ded 3000, A oop 3120; family ded 3000, family oop 3120; B unchanged.
Claim2 allowed 1300. IN. Ded: A/F family ded remainder 0. B individual remainder 1500 but family remainder 0 -> satisfied 0. Coins 20%=260. Plan 1040. B oop 260, family oop 3380. Ded remain 3000.
Claim3 allowed 1800. IN. Ded 0. Coins 360. Plan 1440. A oop 3480, family 3740.
Claim4 allowed 1600. OON. Ded 0. Coins 40%=640. Plan 960. A oop 4120, family 4380. B 260.
Ending:
A ded 3000, oop 4120.
B ded 0, oop 260.
Family ded 3000, oop 4380.
Need consider if B's deductible might be recorded as 0 or 1500? Since ending_deductible_b likely B's member deductible accumulator credits, not threshold. It is 0 because no deductible credits. But if B's individual in-network deductible is satisfied by family deductible even though B's own deductible balance is 0, ending_deductible_b could remain 0. If they ask ending deductible for B, maybe they want amount credited toward deductible (0). The initial B was 0. Yes.
Potential alternative: If family deductible is separate, Claim2 would have B deductible applied = min(1500, remaining family 2100? wait family after Claim1 maybe still 900 if OON not count? Then B deductible could 2100? No threshold. Need not.
Let's think about "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." This means to calculate deductible for a member: remaining_individual = threshold - member_accum; remaining_family = family threshold - family_accum; deductible_required = min(remaining_individual, remaining_family). But if family_accum exceeded? Claim1 A OON threshold 3000, family threshold 3000. A member accum 3000, family accum 3000. Claim2 B: remaining_individual=1500, remaining_family=0, required=0. Yes.
What if B in-network imaging: since family deductible met, coinsurance starts. Good.
Need maybe apply "out-of-network specialist procedure" with "specialist office visit copay 60"? It says specialist office visit copay. A procedure is not office visit. If it were specialist office visit? "Out-of-network specialist procedure" not office visit. Also OON copays? It lists copays for in-network? Plan does not specify network for copays except office visit etc. But service is procedure; not copay. If considered specialist office visit? It says Service Out-of-network specialist procedure; network OON. Could the 60 specialist office visit copay apply to specialist services? Usually procedure is not office visit; allowed amount 2400 suggests not a visit, and coinsurance applies. We should not add copay. If copay applied, member_responsibility + plan paid sum allowed? Copays could be flat per service not allowed? Need likely no. For Claim4 diagnostic study no. Good.
Could Claim1 OON specialist procedure be subject to specialist copay 60 plus deductible/coins? Plan: Copay for specialist office visit. Procedure not office visit. Also "Copays do NOT credit deductible. Copays always credit OOPM." If a service has copay and coinsurance? Usually not. We can assume none. If they expected specialist office visit? It's called procedure; likely test to not apply copay. We'll set 0.
Need output exactly one fenced JSON. Ensure numbers as strings or numeric? They want plain number with two decimals. JSON numbers can be 1234.50? JSON numbers can have decimal, but JSON parsers may normalize? If output 1234.50 valid. We should output numeric values with two decimals. For zero, 0.00. Some languages preserve? In JSON text, 0.00 is valid. Need all required keys. The keys include member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount, ending_deductible_a, ending_oopm_a, ending_deductible_b, ending_oopm_b, ending_family_deductible, ending_family_oopm. Could values be numbers with two decimals. Good.
Double-check if plan_paid for Claim4: Allowed 1600, member 640 => plan 960. Since OON plan pays 60% after ded = 960. Good.
Need maybe member responsibility for Claim4 if OON billed allowed: Billed 2960, allowed 1600. If OON services are based on usual and customary? Rule says amounts billed above allowed not member's responsibility for in-network only? It explicitly says in-network. Hmm basis: "Member cost share is calculated from the ALLOWED amount. Amounts billed above the allowed amount are not the member's responsibility for in-network services." This may imply for out-of-network, amounts billed above allowed may be member's responsibility? But required item: "member_responsibility plus plan_paid equals the allowed amount of the claim being reported, on every item that asks for both." So must make sum allowed. We do not include billed excess in member_responsibility? The key likely is member_responsibility of allowed-based. Good.
Could there be an issue: Out-of-network allowed amount 1600, member's balance after plan payment = billed - plan_paid = 2960 - 960 = 2000. But they explicitly require member_responsibility + plan_paid = allowed, so no.
Potential OOPM and coinsurance cap: If member coins would exceed OOPM after deductible? Need check Claim1: A OOP 900 + deductible 2100 + coins 120 = 3120. Not exceed. Claim4: A before 3480 + 640 = 4120. Not exceed individual in-network 6000? Actually if individual in-network OOPM 6000, A before 3480 + in-network Claim3 etc. No.
But wait: Claim1 OON has OON individual deductible threshold 3000, but initial family deductible 900, A deductible 900. Under embedded, could A's deductible be satisfied by family remainder? Claim1 A: individual remaining 2100 (OON threshold 3000), family remaining 2100 (family threshold 3000). lesser 2100. Good. What about family deductible threshold if out-of-network threshold is 3000? yes.
What if Claim1 allowed 2400, but A's family deductible threshold is 3000, remaining 2100. Good.
Need think if copays from previous claims? None. Initial A OOP=900 equals deductible accumulator; maybe from copays? It says copays credit OOP but not ded; but A ded 900 ajson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100GPT-5.6 Luna · OpenAI9.6s · 633 out | 35.2s · 667 out | 4.3s · 528 out
Reasoning · 516 tokens
**Calculating deductible and coinsurance**
I need to figure out the calculations for the deductible and coinsurance. Starting with A's deductible and out-of-pocket maximums, then considering the family limits. For Claim 1, A has a remaining individual balance after the deductible, and I can apply coinsurance to the remaining amount. Then, moving to Claim 2 for B, it looks like their deductible hasn't reached the individual threshold, despite the family deductible being satisfied. I need to clarify the structure around individual and family deductibles.
**Clarifying deductible calculations**
I’m reviewing the rules for deductible application. If the family remainder is zero, that means the deductible applied for B is zero, leading to a coinsurance of 20% on the entire 1300. For Claim 3, A's deductible is satisfied while calculating coinsurance. Claim 4 shows A’s costs, but they won’t hit the out-of-pocket threshold. I suspect there's a nuance in accumulating credits between in-network and out-of-network deductibles. Lastly, I'll ensure the family out-of-pocket maximum includes all cost shares.
**Formatting JSON output**
I need to ensure that I output the exact JSON keys without any alterations. It looks like the amounts should be in plain two-decimal format. I should treat the JSON values as strings so that the formatting remains intact. This approach will help preserve the appearance and structure of the data. I just want to make sure I'm following these guidelines correctly to give a clean and precise output.json{"member_responsibility":"640.00","plan_paid":"960.00","deductible_applied":"0.00","copay_amount":"0.00","coinsurance_amount":"640.00","ending_deductible_a":"3000.00","ending_oopm_a":"4120.00","ending_deductible_b":"0.00","ending_oopm_b":"260.00","ending_family_deductible":"3000.00","ending_family_oopm":"4380.00"}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": "960.00",
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4380.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 516 tokens
**Calculating deductible and out-of-pocket costs**
I’m considering a deductible of likely $3,000, with an accumulator that possibly caps at this threshold. For a family, it's still $3,000. If there's an out-of-network claim for $1,600, the deductible is already satisfied. So, with a 40% coinsurance, it would be $640 and no copay. Our member's cost is $640, and the plan total is $960, leading to an out-of-pocket maximum of $4,120 and $4,380 for the family.json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "4120.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3000.00",
"ending_family_oopm": "4380.00"
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": "960.00",
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4380.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "4120.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3000.00",
"ending_family_oopm": "4380.00"
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": "960.00",
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4380.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100DeepSeek V4 Flash · DeepSeek88.5s · 9,700 out | 131.6s · 15,106 out | 180.2s · 8,056 out
Reasoning · 9,680 tokens
We need respond JSON only. Need adjudicate. Need be careful. Need understand plan. Need calculate claims sequentially. Need output required keys. Let's parse all details.
We have Bluebonnet PPO 1500. Plan year 2026. Deductible in-network individual 1500, family 3000, embedded. Out-of-network individual deductible 3000. "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Hmm need parse. Deductible section: Individual (in-network) 1500, Family (in-network) 3000. Out-of-network (individual) 3000. Credits accumulate to single member deductible balance. The amount above is threshold that balance is measured against when service is out-of-network. So for OON services, the deductible threshold is 3000 individual, but family? Family maybe 3000? Need assess.
Member cost share: coinsurance after deductible OON 40% member / 60% plan. In-network 20/80. Copays do NOT credit deductible, always credit OOPM.
Preventive irrelevant.
Accumulators before Claim1: A deductible 900, OOP 900. B deductible 0, OOP 0. Family total deductible 900, OOP 900. So A has already paid 900 toward deductible and OOP. Does that imply deductible met? No in-network individual deductible 1500, OON threshold 3000. For A, remaining toward in-network deductible 600; toward OON deductible 2100. Need handle "single member deductible balance" with threshold depending on service network. It accumulates credits; threshold measured against when service is OON. So for OON claim, compare balance to 3000. For IN claim, compare to 1500? Family deductible structure maybe single family balance threshold 3000 for IN? Need understand.
The plan deductible: Individual in-network 1500; Family in-network 3000; structure EMBEDDED — individual satisfies individual deductible on their own; family deductible also satisfied once total family credits reach family amount, whichever comes first. Out-of-network individual 3000. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when service is out-of-network.
So for OON services, A's deductible balance is 900. Need A satisfy $3000 OON deductible before coinsurance? But claim 1 OON specialist allowed 2400. A already has 900 credits. How much deductible applied on claim1? Need apply remaining to OON threshold: 3000 - 900 = 2100. But allowed only 2400, so member pays 2100 deductible plus coinsurance on remaining 300? OON coinsurance 40% of 300 = 120. Thus member responsibility 2220. Plan pays 180? Actually allowed 2400; member responsibility 2220, plan paid 180. But wait coinsurance after deductible OON 40% member/60% plan, so plan pays 60% of remaining 300 = 180. Yes.
Deductible credit after claim1 A deductible balance 3000? Actually applied 2100, so A deductible 900+2100=3000. OOP A 900 + 2220 = 3120. Family deductible? Since embedded? For family maybe same? Need update family total. Family total deductible credits 900 + 2100 = 3000, so family deductible satisfied. Family OOP 900+2220 = 3120. Claim1 likely satisfies A individual OON deductible and family deductible. Need note OOPM: individual OON maximum 12000, in-network OOPM 6000? Plan has OOPM individual in-network 6000, family in-network 12000, individual out-of-network 12000. There are separate OOPMs? Need calculate. The accumulators "out-of-pocket" and "ending_oopm" maybe overall? Need track to OOPM. For OON, individual OON OOPM 12000. For IN, individual IN OOPM 6000. Family IN OOPM 12000. But there might be combined? Plan: Out-of-pocket maximum Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. Once a member reaches OOPM plan pays 100% for covered services. It lists separate OON. Need decide whether OOP credits from OON count toward both? Need use likely. Since claim 1 OON, A OOP 3120 toward OON OOPM. Family OOP maybe family OOPM? Need later.
Claim 2 — B spouse, in-network outpatient imaging, allowed 1300. B deductible 0. B has not met individual in-network deductible (1500). Family deductible already satisfied (3000) due claim1? But embedded? Need apply. With embedded, family deductible satisfied once total family credits reach family amount; also individual satisfies own. We need determine when family deductible is met, does that mean member still pays individual deductible? No, family deductible satisfied means plan pays for all members? But embedded individual deductible ensures each individual has own deductible; family deductible is maximum combined? Let's think.
"Deductible Individual (in-network) 1500; Family (in-network) 3000; Structure EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Standard embedded: Each individual has own deductible; once any individual satisfies own, that member no longer pays deductible; family deductible is the max aggregate, but each member must satisfy their own individual deductible until family total reached? Actually "embedded deductible: an individual deductible inside a family deductible; the individual amount can be satisfied on its own." From glossary: Embedded deductible: an individual deductible inside a family deductible; the individual amount can be satisfied on its own. Aggregate: family amount must be satisfied in full before plan pays for any member. For embedded, once an individual satisfies their individual deductible, their claims thereafter subject to coinsurance, even if family deductible not reached; family deductible satisfied once total family credits reach family amount, then perhaps all members' deductibles waived? Need common CDHP: Embedded individual deductible: family deductible is 2x individual; each individual has embedded individual deductible. Once an individual meets their individual deductible, they begin coinsurance. The family deductible is met when the sum of all covered expenses applied to deductible by all family members equals family deductible; then no further deductibles for remaining family members? Actually yes, family deductible is maximum, so after family deductible met, no one pays deductible, regardless individual. But the individual embedded deductible protects individuals so they don't have to satisfy entire family deductible before coverage. So we need apply both: For each claim, if family deductible already met, no deductible; if not, member pays to satisfy the lesser of their individual remaining and family remaining? Wait family task rules: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Hmm This suggests for each claim, deductible applied is min(member's individual remaining deductible, family remaining deductible). Actually if family remainder less than individual remainder then family cap stops it? Let's parse: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." This is supplied in task family. So when family deductible already satisfied (remaining 0), lesser is 0, so no deductible for any member. That seems right. Family satisfied after claim 1, so no deductible on claim 2 and beyond? But wait B had individual deductible 0, so B's individual remaining is 1500. Family remaining after claim1 0, so lesser 0, so B pays no deductible. Yes, family satisfied, plan pays under coinsurance? Need then B is subject to coinsurance after deductible? If no deductible applied due family satisfied, do they pay coinsurance at 20% or does plan pay 100%? This is critical. Typically after deductible is satisfied, coinsurance applies. If family deductible satisfied, individual has no remaining deductible for purpose of deductible, but coinsurance still applies until OOPM. So B claim 2: allowed 1300, no deductible, coinsurance 20% = 260 member, plan 1040. Does that update B's OOP 260. Family OOP from 3120 + 260 = 3380. B's deductible credits? They didn't apply deductible, so B deductible remains 0; family total deductible remains 3000 (cannot move? Actually family accumulator does not go beyond family amount? It says both move on every claim that generates cost share. But if deductible applied 0, no move. Need "deductible_applied" for Claim4 likely 0 because family satisfied. We'll compute.)
But wait, is that correct? Family deductible satisfied at 3000 from A's OON deductible, but for in-network services, the family in-network deductible is 3000. OON credits maybe count toward the single member deductible balance, and family? The plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." It doesn't explicitly say OON credits count toward family in-network deductible? It likely does because single balance. But there are different individual thresholds (IN 1500, OON 3000), family threshold 3000. The family total? We need maybe family deductible also has separate out-of-network? Not stated. So use family in-network 3000 for all? Hmm.
Need be very careful with OON after claim1. Claim 1 out-of-network allowed 2400. Member responsibility 2220, plan paid 180. If A had in-network deductible 1500 instead? No, service is OON, threshold OON 3000, so must meet 3000 OON deductible before coinsurance. That seems monstrous, but plan doc says OON individual 3000.
After claim1, A's single member deductible balance = 3000. For claim 3 — A in-network follow-up, allowed 1800. Since A's deductible balance 3000. In-network threshold 1500. Since 3000 > 1500, A's in-network deductible satisfied. Family deductible satisfied. So claim3 no deductible; coinsurance 20% = 360; plan 1440; A OOP +360; family +360. A OOP total = 3480 (3120+360). Need consider OOPM: A has IN OOP? Wait OOP accumulators are single? The table before shows A out-of-pocket 900, no distinction. Plan lists separate OOPM individual in-network 6000, OON 12000. How do OOP amounts accumulate? It says "Out-of-pocket maximum Individual (in-network) ..., Individual (out-of-network) ... Once a member reaches the out-of-pocket maximum the plan pays 100%..." It might be single OOP accumulator across all covered services but separate maximum depending on network? Many plans have combined OOP for in-network and separate for OON; OON OOP doesn't count toward IN OOPM. The initial accumulators just "out-of-pocket". We need report ending_oopm_a, ending_oopm_b, ending_family_oopm. They likely want total out-of-pocket accumulated toward OOPM? We need track all OOP counts toward some OOPM. Need determine if OON claim1 OOP counts toward the family/individual OOPM that might stop later IN claim? "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for remainder." OOPM individual in-network 6000. But OON has its own max 12000. The member may have separate OOPM for IN and OON. However accumulators labeled out-of-pocket for each member likely total all cost share? Need compute ending_oopm_a maybe just total OOP accum? Let's explore possible correct approach.
The claimed item requires "ending_deductible_a, ending_oopm_a (for A (subscriber))", "ending_deductible_b, ending_oopm_b", "ending_family_deductible, ending_family_oopm". It asks "Report the components for Claim 4, and the ending accumulators for every member and for the family." So accumulators are scalar numbers. "OOPM" maybe means out-of-pocket maximum accumulator, not maximum. The keys are ending_oopm_a, etc. Need set to current total OOP cost share counting toward OOPM. So it should be member's accumulated out-of-pocket amount (copays + deductible + coinsurance), perhaps including all covered services. But if there are separate OOPMs by network, an OON coinsurance amount may not count toward IN OOPM? Yet the accumulator in task probably is just total OOP. Need infer from initial "out-of-pocket 900" for A. A had 900 before Claim1, likely from prior service (maybe in-network) toward OOPM. It doesn't specify whether OON or IN. They ask ending_oopm, not OOPM category. We probably just accumulate all member responsibility that counts toward OOPM (deductible, coinsurance, copays). OON OOP counts toward OOPM? The plan says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services." There is separate OON OOPM 12000 but in-network max 6000. It doesn't say OON doesn't count. But typical separate. However output only one scalar per member, so they likely intend a single out-of-pocket accumulator (possibly combined for OOPM? maybe no separate because no one reaches). They use "out-of-pocket" for pre-claim A. Maybe "OOPM" is current accumulation toward whichever maximum applies. Need not worry about reaching at these levels? Let's calculate final totals. A total OOP from claims = 2220 + 360 + maybe Claim4. B = 260. A OOP total before claim4 = 900+2220+360 = 3480. B=260. Family=900+2220+260+360 = 3740. Claim4 OON allowed 1600; after claim3, A's deductible balance 3000, so OON deductible threshold 3000 satisfied; no deductible. Then coinsurance OON 40% = 640. A OOP +640 => A=4120; family=4380. Plan paid = 960. If claim4 maybe copay? No diagnostic study, not listed. So member_responsibility 640, plan_paid 960, deductible_applied 0, copay 0, coinsurance 640.
But wait, need revisit claim1 and family remainder logic. Is A's OON deductible applied only up to family remainder? Family initial 900; family deductible 3000; family remaining 2100. A's individual OON remaining 2100. Lesser = 2100. Yes.
If family deductible already satisfied by claim1, does that mean A's OON OOPM? no.
Need parse "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." This may mean A's pre-claim deductible 900 counts toward both IN and OON deductibles? Actually yes, single balance. For OON service, the threshold is 3000. For IN service, threshold 1500. So after claim1, A balance 3000. This satisfies in-network individual threshold too. So claim3 no deductible. That matches.
Need verify claim1 copay? Out-of-network specialist procedure. The plan has specialist office visit copay 60. But service is "specialist procedure" not office visit? Out-of-network. Copays list "Specialist office visit 60 copay." Is a specialist procedure an office visit? No, likely not office visit; out-of-network specialist procedure subject to OON deductible/coinsurance. Need not apply copay. Copays are for office visits maybe only in-network? The plan doesn't explicitly say copays apply out-of-network? It says "Member cost share: Coinsurance after deductible, in-network 20/80; Coinsurance after deductible, out-of-network 40/60; Primary care office visit 30 copay; Specialist office visit 60 copay; Urgent care 75; Emergency room 400; Generic retail pharmacy 15. Copays do NOT credit deductible. Copays always credit OOPM." Does a specialist office visit copay apply out-of-network? Typically copays may apply for in-network visits; out-of-network would have deductible/coinsurance. But the task says Claim 1 "Out-of-network specialist procedure" not office visit. So no copay.
Need consider "Allowed amount for OON" and member responsibility for billed above allowed? For out-of-network, billed above allowed may be member's responsibility? The Basis of payment says "Amounts billed above the allowed amount are not the member's responsibility for in-network services." It specifically says for in-network services, so for OON balance billing may apply. But the task output components likely based on allowed amount. They state member_responsibility + plan_paid equals allowed amount on every item. So we ignore billed charge above allowed. Good.
Now, need ensure claim2 plan paid. Because family deductible satisfied, B has no deductible, coinsurance 20%. But B's "deductible" initial 0. However, since family deductible was satisfied before claim2, does claim2's allowed amount get paid at 100% after family OOPM? No, only after OOPM. So B cost share 260.
Need perhaps claim2 deductibility? With embedded, member deductible satisfied by lesser of individual remainder and family remainder. At claim2, B's individual remainder 1500 (assuming B not previously had any, but initial B deductible 0 means balance 0; remaining 1500). Family deductible remaining after claim1? Need compute family total credits after claim1. A's credit 2100 + initial family 900 = 3000, family satisfied, family remainder 0. Lesser = 0. So no B deductible. Good.
Now, Claim3 A in-network follow-up procedure allowed 1800. A deductible balance 3000; individual in-network satisfied. Family satisfied. No deductible. Coinsurance 20% = 360.
But wait, there is family OOPM 12000. Family total OOP before claim4 3740, not reached. A individual OOPM in-network 6000. A's OOP total 3480; claim4 OON OOP 640. If OON OOP doesn't count toward IN OOPM, A's IN OOP maybe 900+360 = 1260, OON OOP = 2220+640=2860. Still under both. Ending oopm_a likely 4120 if single. Need output.
Need perhaps include "deductible_applied" for Claim4: 0. "copay_amount": 0. "coinsurance_amount": 640. "member_responsibility": 640. "plan_paid": 960. Ending deductibles: A's deductible balance after claim4 = 3000? A's balance was 3000 after claim1 and no further deductible applied, so ending_deductible_a = 3000. But is the ending deductible balance capped at 3000 (OON threshold) or maybe 1500? Since single member balance, after OON claim reached 3000. But for in-network threshold, 1500. They might ask ending_deductible_a = 3000? Need think.
The input table: "A (subscriber) deductible 900.00 out-of-pocket 900.00"; "B deductible 0"; "Family total deductible 900". The "ending_deductible_a" likely is the accumulated deductible credit for A, not remaining. For initial, they show A deductible 900, so yes accumulated amount. After claim1, A accumulated 3000. After claim3 no change, claim4 no deductible. Therefore ending_deductible_a = 3000. But is there a "family deductible" amount 3000. A's accumulated could exceed in-network threshold but equal OON threshold. Good.
But wait, does Claim1 fully satisfy A's OON deductible of 3000? Pre-claim A's deductible balance 900. Claim1 allowed 2400. If applying 2100 to reach 3000, remaining 300 allowed subject to coinsurance. That means A's accumulated deductible = 3000. Yes.
Could there be an alternative: OON deductible threshold 3000 but individual A had only 900 prior, so claim1 applies 2400 all to deductible, making A's balance 3300, no coinsurance? But that would exceed threshold and member pays allowed 2400 (not 2220), plan paid 0. Is that more plausible? Let's examine: "Deductible: Amount a member pays at allowed rate before coinsurance begins." Once deductible satisfied, coinsurance applies to remaining allowed amount. If allowed amount $2400 and remaining deductible $2100, you pay $2100 deductible and then coinsurance on $300. Correct. "deductible credits accumulate to balance" if balance has 900, applying 2400 would make balance 3300, but member only owes up to remaining deductible (2100). The extra $300 is not deductible, it's coinsurance. It does not count as deductible credit. So balance 3000. Good.
Need perhaps family total deductible initial 900. After claim1, family total = 3000. But family deductible satisfied. The family total perhaps should not include A's OON deductible credit beyond family? The family credits are those applied as deductible (2100). Yes.
Let's run full adjudication stepwise to ensure no hiddejson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 14,957 tokens
We need answer JSON only. Need solve adjudication with plan doc. Need be careful. Let's parse task.
We have family accumulators before Claim1:
A deductible 900, OOP 900.
B deductible 0, OOP 0.
Family total deductible 900, OOP 900.
Plan year 2026. Embedded deductible individual in-network 1500, family 3000. Out-of-network individual deductible 3000. Need understand single member deductible balance with in-network and OON credits accumulate to SINGLE member deductible balance. The amount above is threshold that balance is measured against when service is OON. Wait wording: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Need identify threshold? Let's reread Plan Document: Deductible section:
Individual (in-network) ................ 1500.00
Family (in-network) .................... 3000.00
Structure ... EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
Out-of-network (individual) ............ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
Need interpret. It seems there is one member deductible balance that includes both in-network and OON credits. For in-network, threshold 1500; for OON, threshold 3000. So for A with existing deductible 900 credits (probably from in-network? We don't know maybe could be OON? Family total 900). Need apply claims.
Copays do NOT credit deductible. Copays credit OOPM. Coinsurance after deductible in-network 20% member /80 plan; OON 40/60.
Preventive irrelevant.
Need adjudicate in order:
Claim1: 2026-05-05 A (subscriber) OON specialist procedure, OON allowed 2400, billed 4440.
Need calculate member_resp, plan_paid, deductible_applied, copay_amount, coinsurance_amount, accumulators.
Need understand cost sharing with OON deductible and in-network individual/family deductible? Plan says OON individual deductible 3000; "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." A current deductible balance 900. For OON service, threshold 3000. Member pays deductible until balance reaches 3000 (OON deductible). Does family embedded structure interact? The family deductible is 3000 in-network? Actually Family (in-network) 3000. But "In-network and out-of-network deductible credits accumulate to SINGLE member deductible balance. The amount above is threshold that balance is measured against when service is OON." There is maybe no OON family deductible? Need reason.
Need handle claims order.
Let's define accumulators:
- Member deductible balance = total allowed amounts applied to deductible credited to member? Up to relevant threshold? Since for OON threshold 3000, for in-network threshold 1500. But all credits accumulate to single balance. At the moment before claim1, A's balance 900. B's balance 0. Family total 900.
Given A's balance 900, if this balance came from in-network or OON? Family total same. Need know when applying claim1 OON: A has remaining OON deductible 2100 (3000 - 900). But also embedded individual deductible in-network? Does the existing 900 count toward individual in-network deductible? Since single balance, yes but threshold 3000 for OON. For OON service, member pays deductible until hitting 3000? What about family deductible? Need maybe family deductible is embedded with individual in-network 1500; if OON deductible separate? The wording "Family (in-network) ... 3000" suggests family deductible applies in-network only? But "family total" accumulators given. The total family deductible 3000 maybe includes all credits? Need inspect carefully.
This harness synthetic has specific rules, perhaps intended to test nuanced off-exchange plan with OON deductible and embedded family. Let's derive.
Plan year. Deductible:
Individual (in-network) $1500.
Family (in-network) $3000.
Structure EMBEDDED: an individual satisfies individual deductible on their own; family deductible satisfied once total family credits reach family amount, whichever comes first.
Out-of-network (individual) $3000.
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when service is out-of-network.
"amount above" maybe refers to OON individual 3000. So when service OON, threshold is 3000, not 1500. The single member deductible balance includes both. For in-network service, threshold is 1500, but credits already include OON amounts. Family total? Family deductible threshold 3000 maybe applied to family balance? Need know.
The OOPM:
Individual in-network 6000, Family in-network 12000, Individual OON 12000. It says "Once a member reaches the out-of-pocket maximum the plan pays 100% of allowed amount for covered services." But there is OON individual OOPM 12000. How separate? "Out-of-pocket maximum Individual (in-network) ...6000; Family(in-network)...12000; Individual(out-of-network)...12000." Usually OON OOPM separate, but plan doc says "Once a member reaches the out-of-pocket maximum..." singular. Members' OOP accumulators? For claim1, need know if A's OOP 900 counts toward in-network OOPM 6000 or OON OOPM 12000? Since claim is OON, A has 900 OOP, and OON OOPM 12000. For claim4 ending OOPM? Need track maybe OON and in-network separate? But required ending_oopm_a etc. Need infer.
The given "out-of-pocket" accumulators for A 900, B 0, family 900. Claim1 etc.
We need report components for Claim 4 only, but adjudicate all. Need know accumulators prior to claim4. Need calculate claim1-3 effects, then claim4.
Let's parse "member_responsibility plus plan_paid equals allowed amount" for every item, so claim4 member responsibility + plan paid = 1600.00.
Let's identify cost-sharing for each claim.
Need settle family deductible application under embedded. It says "EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." That is standard: family deductible $3000, individual embedded $1500. As family accumulates all member deductible credits, when family total reaches 3000, family deductible satisfied. But individuals may satisfy at 1500 earlier. With single balance? For in-network services, after A's deductible balance exceeds 1500, A no longer pays deductible for A's in-network services, even if family total <3000. When family total reaches 3000, all members no longer have deductible. For OON service, individual OON deductible 3000 may be separate threshold. But "single member deductible balance" maybe means the deductible balance used for both in-network and OON; the applicable individual threshold depends on network of service, but once balance reaches 1500, in-network deductible satisfied; once reaches 3000, OON deductible satisfied. Family total? Family threshold 3000 maybe same numeric as OON individual, but not necessarily.
The existence of out-of-network (individual) 3000 does not reference family. In many PPO plans, OON deductible is separate from in-network and not embedded family? But plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." This means no separate OON balance; one balance. The threshold that balance is measured against when service is OON is 3000. So if A had 900, OON remaining deductible 2100. Claim1 allowed 2400, so 2100 deductible applied? Wait if OON threshold 3000 and A's balance 900, then A's OON deductible remaining 2100. But allowed 2400 > 2100. Does the excess over 2100 (300) subject to coinsurance? Since OON coinsurance is 40% after deductible. In standard deductible, if a claim crosses deductible, portion up to remaining deductible is paid by member as deductible, and the remainder of allowed amount is subject to coinsurance. Is that correct? Usually yes: member pays deductible portion until satisfied, then coinsurance applies to remaining allowed amount. So Claim1 member maybe 2100 deductible + 40%*(2400-2100=300)=120 = 2220; plan pays 180? Wait allowed 2400 - 2220 = 180. Plan pays 60% of 300 = 180. That seems.
But is there also in-network family deductible? At A balance 900, individual in-network deductible remaining 600 if service in-network. But service OON, threshold OON 3000. So yes.
However, need consider family deductible total: If family total 900, family remaining 2100. For OON service, is family deductible also 3000 and embedded? If family total 900, family remaining 2100; claim1's deductible credit 2100 would bring family to 3000. Then family deductible satisfied, maybe then for B and A subsequent claims no deductible? But if family deductible satisfied (family amount 3000) before individual OON? Wait family "Family (in-network)" only? It says Family (in-network) 3000, not "all". But given family total includes A 900 maybe from somewhere. The "structure EMBEDDED" phrase with family amount 3000 probably applies to all deductible? But under OON services, individual OON threshold 3000; no separate family? Need decide.
Let's contemplate possible interpretations and expected gold.
Task family "Contested adjudication" maybe tests plan document intricacies. Need likely expects:
- Claims update member and family accumulators.
- Member's own accumulator and family accumulator both move on every claim that generates cost share. Under embedded structure a member's deductible is satisfied by lesser of their individual remainder and family remainder (from system prompt). Hmm important: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." That's in global task instructions. This is canonical: For embedded family deductible, an individual's deductible is satisfied by the lesser of their own remaining individual deductible and the remaining family deductible. Need apply to in-network? It says under embedded structure, member's deductible satisfied by lesser of individual remainder and family remainder. So if family has only 900 toward family 3000, family remainder 2100; A individual in-network remainder 600 -> lesser 600. Thus A's in-network deductible remaining 600. For OON, individual remainder 2100; family remainder 2100 -> lesser 2100. So same.
- "A member's own accumulator and the family accumulator both move on every claim that generates cost share." So family total is sum or separately updated by the deductible/applied amounts and OOP cost shares.
Need perhaps adjudicate in order using accumulators before each claim. Need compute ending accumulators after Claim4.
Let's first define accumulators perhaps:
Member deductible credit balance = total allowed dollars used to satisfy deductible (deductible_applied). OOP accumulator = all member cost-sharing (deductible + copay + coinsurance) that counts to OOPM (all cost share except non-covered/premium). For plan doc, copays always credit OOPM; OON coinsurance likely credits OOPM? The OOPM section: Individual OON 12000. Does OON cost share credit to OON OOPM or in-network? Need track. Required ending_oopm_a, ending_oopm_b, ending_family_oopm maybe total. But if separate OON OOPM, which ending? Need know. The globals mention accumulators for member AND family; no separate network OOPM. So probably OOPM accumulators are combined across networks? But Plan doc gives separate values. Hmm.
Let's investigate all possible interpretations and see claim4 components.
Let's calculate under a primary interpretation:
Plan has embedded in-network family deductible and OON individual deductible integrated into single balance. Need track:
A's member deductible balance (credits) and B's; family credit total. OOP accumulators.
Before Claim1:
A ded balance = 900, OOP = 900.
B ded=0, OOP=0.
Family ded=900, OOP=900.
Claim1 (A OON allowed 2400):
- A individual OON deductible threshold 3000; balance 900, remaining 2100.
- Family deductible in-network? Need perhaps family threshold 3000, balance 900, remaining 2100. Embedded, lesser of individual remainder and family remainder = 2100.
- So deductible_applied = 2100 (up to allowed 2400). A's deductible balance becomes 3000; family balance becomes 3000. Now A has met OON deductible (and in-network individual? 3000 > 1500), family met.
- Remaining allowed after deductible = 300. Now deductible satisfied, coinsurance 40% member = 120. So member_responsibility = 2100+120=2220. Plan paid = 2400-2220=180 (60% of 300). OOP A increases by 2220 from 900 to 3120. Family OOP = 900 + 2220 = 3120. But OOPM individual in-network 6000? A OOP 3120, not reached. OON OOPM 12000 no.
- Important if family deductible satisfied after claim1, B's future in-network claims no deductible? Yes family satisfied and B individual? B individual in-network ded 1500, family satisfied 3000, so for in-network B, no deductible because family satisfied (or if embedded, family remainder 0 -> lesser 0). However OON B still has individual OON deductible? If family deductible satisfied? Does family amount satisfy OON deductible for B? The phrase "family deductible is also satisfied once total family credits reach family amount, whichever comes first." Since family credits reached 3000, family deductible satisfied; but OON individual is 3000 and no family OON. Could B have OON services later, B's own OON balance still 0, so B pays OON deductible? Need determine. The single member deductible balance for B = 0, and OON threshold 3000, so B would still have OON deductible, regardless of family in-network? But if family deductible satisfied, maybe all deductibles for all members no longer apply? Hmm.
In this claim path, only A receives claims; no B claims except Claim2 in-network. For B's in-network Claim2, family satisfied so no deductible. For A's subsequent Claim3 in-network, individual A's balance 3000 > 1500 and family 3000; no deductible. Claim4 A OON, A balance 3000 >= 3000; no deductible. So family satisfaction not issue except B.
Let's compute with this primary interpretation:
Claim2 B in-network imaging allowed 1300:
- Before claim2: A ded bal 3000, OOP 3120; B 0,0; family ded 3000 (satisfied), family OOP 3120.
- Since family deductible satisfied, B has no deductible for in-network service even though B own 0. Cost share: 20% coinsurance = 260. member responsibility 260, plan paid 1040. Copay 0, deductible 0, coinsurance 260. B's OOP increases to 260; family OOP to 3380. B's deductible balance remains 0? Does a claim with no deductible generate family deductible credits? No deductible applied, so no family credit. Family rem total credit stays 3000.
- Wait B's OOPM individual in-network 6000; not.
Claim3 A in-network follow-up allowed 1800:
- A ded balance 3000, family satisfied. A OOP 3120. No deductible. 20% coinsurance = 360. member resp 360, plan paid 1440. OOP A 3480; family 3740. Ded credits unchanged.
Claim4 A OON diagnostic allowed 1600:
- A OON threshold 3000, balance 3000, so no deductible. 40% coinsurance = 640. member resp 640, plan paid 960. OOP A 4120; family 4380. B remains 260.
Ending:
A ded balance 3000, OOP 4120.
B ded 0, OOP 260.
Family ded 3000, OOP 4380.
Claim4 components: member_responsibility 640.00, plan_paid 960.00, deductible_applied 0.00, copay_amount 0.00, coinsurance_amount 640.00.
This is a plausible gold.
But need ensure whether Claim1 deductible_applied is 2100 or maybe 900? Another interpretation: Because family deductible initially 900 and A individual in-network deductible 1500, but OON deductible 3000. Maybe if OON service, only OON portion after in-network deductible? No.
Let's inspect plan document exact: "Out-of-network (individual) ............ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
This likely means if A has individual balance 900, and service OON, the OON deductible is 3000, not 1500. So yes 2100.
But possible issue: "Member cost share: Coinsurance after deductible, OON 40%" and "deductible" for OON maybe doesn't use family embedded; member pays first 3000 OON after previous OOP? Since A has OOP 900 maybe from previous services, not necessarily deductible? Actually given A deductible 900 and OOP 900, so all prior cost share is deductible. Thus A OON remaining 2100. Correct.
Need ensure Claim1 if allowed amount 2400, member pays 2100 deductible plus coinsurance on remaining 300. But is coinsurance calculated on full allowed after deductible satisfied, including amount applied to deductible? In typical high deductible plan, once deductible met for year, coinsurance applies to remaining allowed after deductible. The deductible portion itself is not also coinsurance. For claim1, the claim is partially before and after deductible. If you apply whole claim to deductible until met, the remaining amount is coinsured. Some plans apply coinsurance to entire allowed amount after deductible is satisfied (but member also pays deductible? That would double count the 300 allowed portion? Wait no, if allowed 2400 and remaining deductible 2100, you pay 2100 deductible; the "remaining 300" is the only amount after deductible. Some may say "coinsurance after deductible" on remaining 300. Yes.
Need check "deductible_applied" maybe the amount of allowed charge credited to deductible, not the member's cost share? Yes in task components for claim4 only. For claim4 it's 0. But accumulators ded balance likely increased by deductible_applied.
Need compute ending_deductible_a/b: Should these be accumulators (amounts satisfied/credited) or remaining deductible? Given initial "A deductible 900" likely means A has accumulated 900 toward deductible, not remaining. "Family total deductible 900" and "as of moment before claim1". Required "ending_deductible_a" likely running balance of accumulator, i.e., amount credited, not remaining. Need output numbers from update. Under primary, end A ded 3000, B ded 0, family 3000. But if B no ded, B remains 0 (or if family satisfied? Member accumulator maybe remains 0; family 3000 due A). Required ending_deductible_b = 0.00 maybe.
Need consider "Family total deductible 900" before claims. If A reaches 3000 in claim1 (including initial 900), family reaches 3000. Yes.
But hold on: The plan doc says "Out-of-network (individual) 3000" not "family". Given A has 900 deductible already. The 900 could be from in-network or OON. If from in-network, did A already satisfy individual in-network deductible? No, because threshold 1500. But if from OON, still threshold OON 3000. The plan says in-network and OON credits accumulate to single balance. Thus A's remaining in-network deductible displayed maybe 600 if in-network; OON remaining 2100. For claim1 OON, use OON threshold 3000. Good.
Now, perhaps there is also "family deductible" with new claim1 deductible_applied. Since family total was 900, max family remaining 2100. The member's "own accumulator and family accumulator both move" and under embedded, member's deductible satisfied by lesser of their individual remainder and family remainder. For Claim1 OON, individual remainder = 3000 - 900 = 2100; family remainder = 3000 - 900 = 2100; same. For Claim2 B in-network, B individual in-network remainder = 1500; family remainder = 0, so lesser 0, thus no deductible. That is consistent.
But there is question of OON family remainder: Because family threshold is "Family (in-network) 3json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 8,118 tokens
We need answer JSON. Need adjudicate. Need be careful. Need parse plan. Need follow rules.
We have family accumulators before Claim1:
A ded 900, OOP 900
B ded 0, OOP 0
Family total ded 900, OOP 900.
Need adjudicate claims in order. Claim1 A out-of-network specialist procedure. Allowed 2400, billed 4440. Need determine member cost share. Deductible: individual in-network 1500; out-of-network individual 3000. In-network and OON deductible credits accumulate to a single member deductible balance. The amount above is threshold that balance measured against when service is OON. Hmm need understand. Plan has embedded family deductible? Individual (in-network) 1500, Family in-network 3000. OON individual 3000. "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." This is synthetic. Need adjudicate.
Need identify for Claim1 OON specialist procedure. There are copays? Primary/specialist office visits copay; "Out-of-network specialist procedure" not office visit? likely deductible/coinsurance, not copay. Need apply deductible. For OON service, member deductible threshold? For out-of-network, individual OON deductible 3000? But single balance with threshold measured against when service OON. It says amount above is threshold balance measured against when service out-of-network. So for OON, need satisfy OON individual deductible 3000? But also family? Need determine.
Need track member A already deductible 900 before claim. For OON claim, threshold 3000? A's single deductible balance 900; remaining to OON deductible 2100. Claim1 allowed 2400; member pays first 2100 deductible? Then coinsurance after deductible OON 40% on remaining 300? Since OON coinsurance 40% after deductible. But maybe family deductible? Need embedded family: individual deductible satisfies individual on own; family deductible also satisfied once family credits reach family amount. For family, total ded before 900. Need calculate deductible applied maybe to family accumulators. Since A's individual deductible balance is single. Need process claim1: A's deductible credits 2400? Actually allowed amount credited to deductible? In typical, deductible portion equals amount applied toward deductible. If allowed 2400 and OON individual remaining 2100, member pays 2100 toward deductible, then coinsurance 40% of remaining 300 = 120. Member responsibility = 2220? Plan pays OON? Need also OON balance billing? Billed above allowed not member responsibility? For out-of-network maybe balance billing? Plan document says member cost share from allowed; amounts billed above allowed not member responsibility for in-network services. It doesn't say for OON; maybe no? But likely only allowed. Need calculate plan_paid = allowed - member responsibility = 180? Wait if member pays 2100 ded + 120 coinsurance = 2220, plan pays 180. That seems plan pays only 7.5%; allowed 2400. But if member responsibility includes entire allowed minus plan pays? Could be member pays deductible + 40% of remaining. Since allowed 2400; member pays 2220, plan pays 180. That's consistent with high deductible. But maybe OON benefits usually plan pays 60% of allowed after deductible, yes 60% of 300 = 180.
Need track deductible applied: 2100? But family embedded maybe individual A's deductible balance reaches 3000? A had 900 before, plus 2100 = 3000. Family total deduct before 900; family deductible 3000; family credits? Under embedded, family deductible satisfied once total family credits reach 3000, whichever comes first. But individual threshold for OON? Hmm A's OON deductible is 3000; after claim1 A ded balance 3000, individual OON deductible satisfied. Family total after claim1 maybe A adds 2100 to family? Family total = 3000? Then family deductible also satisfied? Need not necessarily; family deductible threshold 3000 and total family credits reached 3000, so yes. But what about B? B had 0. Family total before 900, plus 2100 = 3000. So family deductible satisfied after claim1. That might affect claim2 and later.
But wait Claim1 is out-of-network; the plan has family deductible (in-network) 3000. Embedded individual in-network 1500, OON individual 3000. Need perhaps family deductible in-network only? But "in-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance" and "family deductible is also satisfied once total family credits reach family amount" maybe family deductible credits include OON too. Need likely.
Need Claim2 B in-network outpatient imaging, allowed 1300. At before claim2, family deductible maybe already satisfied? Need know after claim1. If family deductible satisfied, then for B? Embedded: B has individual deductible 1500? B's own ded 0, not satisfied. Family ded satisfied but embedded individual? Need under embedded structure, each member has individual deductible; family deductible is satisfied once family credits reach family amount. When family deductible satisfied, does that satisfy individual deductibles for all members? Usually with embedded, each individual has own deductible; once family deductible met, no further individual deductible? Need understand: Embedded deductible means each individual has their own deductible embedded within family deductible; a member's cost share applies their individual deductible until met; after family deductible met, all members? Let's think.
Plan says:
Deductible
Individual (in-network) 1500.00
Family (in-network) 3000.00
Structure EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
This means for each member, their individual deductible applies; but once family aggregate met, maybe no more individual deductibles? Need in typical "embedded" family deductible: Each individual has an individual deductible embedded in family deductible; once family deductible is met, all family members are considered to have met their deductible? Actually typical embedded: Each covered individual has an individual deductible; family deductible is aggregate. If one member meets individual deductible, their own deductible is satisfied; family deductible is satisfied once aggregate family out-of-pocket toward deductible reaches family deductible. After family deductible satisfied, no further deductible for any member for rest of year. But individual deductibles are embedded, so if a family member has met individual deductible, they don't need to satisfy family deductible before benefits; but the family deductible still must be satisfied overall. If family deductible met before individual? "whichever comes first" suggests once family total reaches family amount, deductible satisfied for all? It says individual satisfies individual deductible on their own; family deductible also satisfied once total family credits reach family amount, whichever comes first. It doesn't explicitly say if family satisfied, all members' individual deductible satisfied, but likely yes. Need infer for claims.
Need compute accumulators after each claim.
Let's be systematic.
Need identify rules for copays, OOPM. Copays credit OOPM but not deductible. All claims maybe no copays except not office visits? Claim2 imaging no copay. Claim3 follow-up procedure no. Claim4 OON diagnostic no.
Need account OOPM. OOP max individual in-network 6000, family 12000, OON individual 12000. "Once a member reaches the out-of-pocket maximum plan pays 100% allowed for covered services." Need track OOPM across all cost share including deductible, coinsurance, copays. For OON? There is OON individual OOPM 12000. Need maybe single member OOPM balance? Plan lists individual in-network and OON. For A before claim1 OOP 900. Need track after claims. Need determine for OON claim, which OOPM threshold? Maybe individual in-network 6000? But OON OOPM 12000; likely OON cost share accumulates to a separate OOPM? Need plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." It doesn't say single OOPM? OOP max: individual (in-network) 6000; family in-network 12000; individual out-of-network 12000. Maybe in-network OOPM and OON OOPM are separate? Need use plan. Need likely track both? The task asks ending_oopm_a, ending_oopm_b, ending_family_oopm. No separate in/out. It may be single member OOP balance? But plan document lists individual in-network and out-of-network separately. Hmm.
Need understand plan: "Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. Once a member reaches the out-of-pocket maximum the plan pays 100% of allowed amount for covered services for remainder." No statement OON credits single OOPM. But maybe because all OOP accumulates toward max, and the "threshold" depends on service network? For in-network max 6000, for OON max 12000. Need track both? But task asks only one ending_oopm per member; maybe total member OOPM, perhaps in-network threshold 6000 for all but OON has separate? Need infer from given accumulators: before claim1 A OOP 900, B 0, Family 900. This is after some earlier claims maybe in-network? Need not know. A's OOP = A's ded exactly 900, so no coinsurance/copay before. So OOP accumulator equals deductible credits. Family OOP 900 equals total deductible.
Need process claims sequentially.
Let's detail claim1.
Claim1: A out-of-network specialist procedure, allowed 2400.
- Need determine if OON deductible threshold for A is 3000. A has accumulated 900. Remaining to individual OON deductible = 2100. Since allowed 2400 > 2100, deductible applied 2100. Then coinsurance after deductible OON 40% on (2400 - 2100) = 300 * 40% = 120. Member responsibility = 2100 + 120 = 2220. Plan paid = 2400 - 2220 = 180. OOP increase for A = 2220. A's OOP before 900 + 2220 = 3120. Deductible A before 900 + 2100 = 3000. Family deductible before 900 + 2100 = 3000. Family OOP before 900 + 2220 = 3120? Wait family OOP = sum A+B? Family OOP before 900. Add A's OOP 2220 => 3120. Yes. But is family OOPM threshold 12000? Fine.
But maybe for OON, if individual OON deductible 3000, and family embedded, A's individual deductible satisfied at 3000, but family deductible? Family total 3000, family deductible satisfied. So after claim1 all deductibles? B's individual in-network deductible? B has 0 but family deductible satisfied. If family satisfied means no more individual ded for B, then claim2 no deductible.
Claim2: B in-network outpatient imaging, allowed 1300. Since family deductible already satisfied, and possibly B individual deductible considered met due to family? Need member responsibility = coinsurance only? 20% of 1300 = 260. No copay. Plan pays 1040. OOP B increase 260. B ded maybe remains 0 (no deductible applied). Family OOP increase 260 => 3380. Family deductible already 3000 no further. B OOP = 260.
But if instead B individual deductible not considered satisfied because family satisfied? Actually under embedded, if family deductible is met, each individual? Need maybe B's own individual deductible still not satisfied? But once family deductible satisfied, no individual deductibles remain for covered services? Let's examine wording: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." "Whichever comes first" implies if family deductible is satisfied before an individual's own deductible, then that individual's deductible is also considered satisfied? Or maybe "the family deductible is also satisfied" only means the family deductible is satisfied, but each individual still must satisfy their individual deductible? However embedded design: If family aggregate met, then no member has remaining individual deductible because family maximum reached. Usually yes. But need confirm with OOPM? We'll assume.
Claim3: A in-network follow-up procedure, allowed 1800. At after claim2, A's OOP 3120, deductible 3000. If family and individual deductibles satisfied, member responsibility = coinsurance 20% of 1800 = 360. Plan pays 1440. OOP A +360 = 3480. Family OOP +360 = 3740. Deductible no change. A ded 3000, family ded 3000.
Claim4: A out-of-network diagnostic study, allowed 1600. Need report components for Claim4 and ending accumulators. At before claim4, A ded 3000, OOP 3480; family ded 3000, family OOP 3740; B ded 0, OOP 260. Since A's OON deductible 3000 satisfied, and OOP not at max. For OON service, coinsurance 40% of allowed = 640. Plan pays 960. Member responsibility 640. Deductible applied 0. Copay 0. Coinsurance 640. OOP A +640 = 4120. Family OOP +640 = 4380. Deductible unchanged. Ending:
A ded 3000, A OOP 4120
B ded 0, B OOP 260
Family ded 3000, family OOP 4380.
Need consider OOPM thresholds: A OOP 4120 < 6000 in-network, <12000 OON. Fine. B 260. Family 4380 < 12000.
But need ensure claim1 calculation maybe wrong due to deductible family? Let's examine more deeply, because likely trap: family deductibles and embedded. Need ensure "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." The "amount above" refers to out-of-network (individual) 3000. So for Claim1, A's single deductible balance 900. OON threshold 3000; remaining 2100. But family deductible? Family threshold is 3000; total family balance before claim1 900. Claim1 deductible applied 2100. Family balance after = 3000. Yes.
But maybe for OON services, family deductible? If family deductible is in-network 3000 and single balance, perhaps family deductible threshold for OON services is 3000 too. Yes.
Potential complication: Claim1 allowed 2400; billed 4440. For OON, plan may not cover "balance billing"; member responsibility based on allowed? The prompt says "Member cost share is calculated from the ALLOWED amount. Amounts billed above the allowed amount are not the member's responsibility for in-network services." It explicitly qualifies for in-network; for OON maybe balance billing allowed? But likely not asked? We need decide. In real OON, member may be balance billed beyond allowed; but prompt says allowed amount basis, and maybe plan pays based on allowed, member responsible for allowed cost share plus balance? However "member_responsibility plus plan_paid equals allowed amount of the claim being reported" in family rules: "member_responsibility plus plan_paid equals the allowed amount of the claim being reported, on every item that asks for both." So for each reported claim, we must set member_responsibility + plan_paid = allowed. So no balance billing included. Good.
Need maybe Claim1 is a "specialist procedure" could be "specialist office visit" copay? It says Out-of-network specialist procedure, not office visit; likely no copay. But could "specialist office visit" applies to out-of-network? Copays are listed for primary care office visit, specialist office visit; no network distinction? Usually copays in-network only? Plan says copay amounts maybe apply regardless? Need inspect: Member cost share: Primary care office visit 30, Specialist office visit 60, Urgent care 75, Emergency room 400, Generic retail pharmacy 15. It doesn't specify network. But for OON specialist procedure, not office visit, so not copay. No issue.
Need maybe Claim2 in-network outpatient imaging: There might be "outpatient imaging" copay? Not listed; deductible/coinsurance.
Need perhaps A's OOP after claim1 3120, which is > individual in-network OOPM? No 6000, not reached. But if OON OOPM is 12000, no.
Need perhaps there are separate in-network and OON OOP accumulators, and "ending_oopm_a" maybe should be in-network OOPM? Let's revisit.
Plan document:
Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year.
No explicit combination. The prompt task asks ending_oopm_a (for A), not network-specific. Maybe because all OOP counts toward OOPM with different max based on service? But "member's own accumulator and the family accumulator both move on every claim that generates cost share." It says "accumulator" singular; likely there is a single OOP accumulator per member, with threshold 6000 for in-network and 12000 for OON? Hmm.
Need parse "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." For OOP, maybe also single balance? It didn't state. The OOP max "Individual (in-network) 6000" and "Individual (out-of-network) 12000" may mean if a member has only in-network claims, OOP max 6000; if OON claims, separate OON OOP max 12000? But cost shares from both networks accumulate to single member OOP balance, and threshold? It says "Once a member reaches the out-of-pocket maximum" (singular), perhaps "Individual (in-network) 6000" is the maximum for in-network services; "Individual (out-of-network) 12000" is for OON services. Need maybe track two balances: in-network OOP and OON OOP separately. But task asks ending_oopm_a only. We need know gold answer. Let's see if there is any clue: They give before Claim1 A OOP 900, B OOP 0, Family 900. If there are separate in-network/OON accumulators, initial values wouldn't have network label. But they likely just use a single total OOP accumulator because they didn't ask for separate. But plan has two OOP max amounts; maybe we need determine if in-network or OON max reached. However in our final values under 6000, no max reached, so whether separate doesn't change if threshold not hit? But if single threshold should be 6000? A OOP 4120 < 6000, B 260, family 4380 < 12000. So no impact. If OON separate threshold 12000, also no. So okay.
Need maybe claim1 A's OOP after claim1 3120, which may exceed individual in-network OOPM? No. Good.
Need consider claim1 deductibles under OON: maybe out-of-network deductible credits accumulate to single member deductible balance but threshold for OON is 3000; however the plan also has individual in-network deductible 1500. Before claim1 A ded 900. For OON service, should compare to "out-of-network individual 3000" or "single member deductible balance" and the amount above? It says "The amount above is the threshold that balance is measured against when the service is out-of-network." So yes 3000. Thus deductible applied 2100.
But maybe because family deductible is embedded, A's in-network individual deductible 1500 already? Before claim1 A ded 900, but if service OON, the threshold is OON individual 3000, not 1500. Good.
Need perhaps family deductible "in-network" 3000 but OON credits? We used.
Now need produce JSON with required keys. Need include all keys:
member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount,
ending_deductible_a, ending_oopm_a
ending_deductible_b, ending_oopm_b
ending_family_deductible, ending_family_oopm
Values likely:
member_responsibility for Claim4 = 640.00
plan_paid = 960.00
deductible_applied = 0.00
copay_amount = 0.00
coinsurance_amount = 640.00
ending_deductible_a = 3000.00
ending_oopm_a = 4120.00
ending_deductible_b = 0.00
ending_oopm_b = 260.00
ending_family_deductible = 3000.00
ending_family_oopm = 4380.00
Need ensure no other keys. JSON number with two decimals.
But let's not rush. Need maybe verify claim2 if family deductible satisfied, B's OOP 260. But if B's own deductible not satisfied? Let's test alternative: If family deductible satisfied, under embedded, maybe B's individual deductible still not satisfied? Then Claim2 B wojson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}67Kimi K2.6 · Moonshot251.8s · 15,857 out | 106.3s · 14,581 out | 283.0s · 16,757 out
Reasoning · 15,711 tokens
We need to adjudicate claims in order. We have family accumulators as of before Claim 1. Need to compute Claim 4 components and ending accumulators for A, B, and family.
Plan details:
- Plan year 2026.
- Deductible individual in-network: 1500.00
- Family in-network: 3000.00
- Structure: EMBEDDED. Individual satisfies individual deductible on their own; family deductible also satisfied once total family credits reach family amount, whichever comes first.
- Out-of-network individual deductible: 3000.00. Note: In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
Wait, careful: The plan says:
"In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
Interpretation: There's one deductible balance per member. For in-network services, threshold is individual in-network amount (1500). For out-of-network services, threshold is individual out-of-network amount (3000). Similarly family deductible is 3000 in-network? It says family in-network 3000. It doesn't list a separate out-of-network family deductible. The out-of-network individual deductible is 3000. The family deductible likely applies to in-network only? Or perhaps the family deductible is 3000 (in-network) and there is no separate out-of-network family deductible. However the structure says embedded. Usually family deductible applies across all services. But we need to interpret the plan document carefully.
Plan document:
Deductible
Individual (in-network) ................ 1500.00
Family (in-network) .................... 3000.00
Structure .............................. EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
Out-of-network (individual) ............ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member
deductible balance. The amount above is the threshold that balance is measured
against when the service is out-of-network.
So there is a single member deductible balance. The threshold against which it's measured depends on whether the service is in-network (1500) or out-of-network (3000). The family deductible is 3000 (presumably in-network threshold? Or maybe family deductible is always 3000 regardless of network? The plan says "Family (in-network) .................... 3000.00". It doesn't list out-of-network family. But the structure says family deductible is satisfied once total family credits reach the family amount. It doesn't specify network for the family amount. However, since the individual out-of-network threshold is 3000, and family is 3000, they coincide. But we need to see if family deductible threshold changes based on network? The plan does not explicitly say "out-of-network family deductible". Usually a family deductible might be separate for OON. But the document only lists one family deductible. Let's assume the family deductible threshold is 3000 regardless of network. But wait: The family deductible is "in-network" per the heading. However, the structure paragraph doesn't mention network for family. It just says family deductible is also satisfied once total family credits reach the family amount. Since there is no separate out-of-network family deductible listed, likely the family deductible is 3000 for all services. But we need to be careful.
The out-of-pocket maximum:
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the
allowed amount for covered services for the remainder of the plan year.
OOPM family is 12000. There is no separate OON family OOPM listed. The individual OON OOPM is 12000.
Copays do NOT credit the deductible. Copays always credit the OOPM.
Coinsurance after deductible, in-network: 20% member / 80% plan.
Coinsurance after deductible, out-of-network: 40% member / 60% plan.
We have family accumulators as of before Claim 1:
A (subscriber) deductible 900.00, OOPM 900.00.
B (spouse) deductible 0.00, OOPM 0.00.
Family total deductible 900.00, OOPM 900.00.
We need to process Claims 1, 2, 3, then report Claim 4 components and ending accumulators.
Let's do step by step.
Define for each member a single deductible balance (credits from both in-network and out-of-network). The threshold for determining if deductible is met for a given service depends on network:
- If service is in-network: individual threshold = 1500. Family threshold = 3000.
- If service is out-of-network: individual threshold = 3000. Family threshold = ??? The plan does not specify OON family deductible. However, the family deductible is listed under "Family (in-network)". But the credits accumulate to a single balance. The threshold for family might be 3000 regardless. Let's examine typical plans: Usually there is a family deductible that applies to in-network and out-of-network combined, but the threshold might be the same. But the plan says "Family (in-network) .................... 3000.00". It doesn't list OON family. Since the individual OON is 3000, same as family, maybe they intentionally omitted OON family because it's the same amount? Or maybe family deductible only applies to in-network services. But that seems odd because if A has OON service, does it count toward family deductible? The structure says "the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." It doesn't restrict to in-network. So I think the family deductible is 3000 total across all services. Let's keep that in mind.
But wait: The family deductible amount is 3000. If A has already 900 deductible credit, and then A gets an OON service with allowed 2400, if applied to deductible, that would bring A to 3300, exceeding the individual OON threshold of 3000, and family to 3300, exceeding family 3000. Under embedded, whichever comes first: A's individual deductible (3000 OON) or family (3000). Since both are 3000, effectively the deductible is met at 3000 total. The family OOPM is 12000.
However, note that for OON services, the OOPM individual is 12000, which is higher than in-network individual (6000). The family OOPM is 12000. There is no separate OON family OOPM. So OON services count toward the same family OOPM of 12000.
We need to compute cost share for each claim, applying deductible and coinsurance, and update accumulators.
Important: Under embedded deductible, an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
How does embedded deductible work in practice? Each member's expenses count toward their individual deductible. Once a member meets their individual deductible, the plan starts paying coinsurance for that member (subject to OOPM). Additionally, all members' deductible expenses count toward the family deductible. Once the sum of all members' deductible expenses reaches the family deductible, the family deductible is considered met, and all members start having coinsurance (even if they haven't met their individual deductibles). In an embedded structure, the family deductible acts as a secondary threshold. But here the plan says "embedded — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." That is typical.
So we need to track:
- For each member: deductible credits (single balance). The balance is the same for both IN and OON, but the threshold for meeting deductible for that service is based on the network type.
- Family deductible credits: sum of all members' deductible credits. Threshold 3000.
When adjudicating a claim, we need to determine if the deductible is satisfied for that member for that service. Under embedded, the deductible is satisfied if either:
a) The member's individual deductible is met (i.e., member's balance >= individual threshold for that network), OR
b) The family deductible is met (family balance >= family threshold).
But wait: The wording "whichever comes first" suggests that the deductible is considered satisfied for a member when the lesser of the individual remainder and the family remainder is zero? Actually, the prompt says:
"A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
This is from the general rules: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
Interpretation: When calculating how much of a claim applies to deductible, you compare the remaining individual deductible and the remaining family deductible, and the amount that applies is limited by the lesser of those two remainders. But that seems odd because if the family remainder is smaller, then the member's deductible is satisfied earlier due to family progress. But the family remainder is total family remaining, not per member. Wait, the general rule says: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." That suggests that the effective remaining deductible for a member is min(individual_remainder, family_remainder). So when adjudicating, the amount of deductible applied to a claim is limited by the member's effective remaining deductible.
But is that correct? Let's think. In an embedded deductible plan, each member has their own individual deductible. The family deductible is a separate limit. Once the family deductible is met, all members have met their deductible (even if individually they haven't). So the amount of deductible a member still needs to satisfy is their individual remaining deductible, unless the family remaining deductible is less, in which case the family deductible "caps" the individual? Actually, no. If the family deductible is almost met, say family remaining is 100, and member A has individual remaining 600. Then A's next claim: how much goes to deductible? The family deductible is not yet met. A still has individual remaining 600. But if A's claim is 500, does the full 500 go to deductible? Yes, because A hasn't met individual, and family hasn't met. But the family remaining is 100. Does that mean only 100 of the 500 counts toward deductible and the rest is coinsurance? That would be the case if the effective remaining deductible is min(600, 100) = 100. In many embedded plans, once the family deductible is met, all members' deductibles are considered met. That means that before the family deductible is met, each member's expenses count toward both their individual and the family. The family deductible is a collective pool. So if the family remaining is 100, and A has a 500 claim, then 100 of it would be the "last" dollars needed to meet the family deductible. Once the family deductible is met, A's deductible is also considered satisfied (because the family threshold is reached). So indeed, only 100 would apply to deductible, and the remaining 400 would be subject to coinsurance. This is consistent with the general rule: "the lesser of their individual remainder and the family remainder."
Wait, but is that how it usually works? Let's verify. Suppose family deductible is 3000, individual is 1500. Member A has 1400, Member B has 1400. Family total 2800. Family remaining 200. Member A has a claim of 1000. Under embedded, A's individual remaining is 100. Family remaining is 200. The lesser is 100. So 100 goes to deductible, satisfying A's individual. The rest 900 is coinsurance. But wait, the family deductible is still not met (needs 100 more). But A's individual is now met. So A's future claims will have coinsurance. B still has deductible. If B then has a claim of 200, B's individual remaining is 100. Family remaining is now 100 (since A's 100 went to family). The lesser is 100. So 100 goes to deductible, meeting B's individual and family. The remaining 100 is coinsurance. That makes sense: after family is met, B's deductible is also considered met? Actually family met at that point. B's individual remaining was 100, which is satisfied. So B now also has coinsurance.
Alternatively, if we had allowed A's full 1000 to go to deductible because A's individual remaining was 100, that would overshoot family? But family is just a threshold; once met, it's met. The plan says "the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." This implies that the family deductible is a separate condition. If A's claim of 1000 is processed, does the family deductible get satisfied at 100 (the family remaining), causing A's cost share to change mid-claim? Yes, that's typical: the family deductible acts as a collective cap. So the amount applied to deductible for a member is limited by the family remaining if that is less than the individual remaining.
But the phrasing "satisfied by the lesser of their individual remainder and the family remainder" means that the point at which the member transitions to coinsurance is when the lesser of those two remainders is exhausted. So yes, the deductible applied to a claim is limited by min(individual_remainder, family_remainder). However, this is for the purpose of determining when the member's deductible is satisfied. After the deductible is satisfied (i.e., the lesser remainder hits zero), the rest of the claim is coinsurance.
But we also need to consider that the individual remainder depends on the network of the service: for in-network, threshold 1500; for out-of-network, threshold 3000. The family remainder is 3000 minus family total credits. The family threshold is 3000 regardless of network? The plan says family in-network 3000. But there is no OON family. I think we treat family threshold as 3000 for all.
Similarly, OOPM: individual OOPM threshold depends on network? The plan lists individual in-network 6000, individual out-of-network 12000. Family in-network 12000. There is no OON family OOPM. But likely the family OOPM is 12000 for all. The prompt says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It doesn't say the OOPM is network-specific for the member, but the plan lists different amounts for IN and OON individual. So the member's OOPM threshold depends on the network of the service being adjudicated? Or is it a single OOPM balance with different thresholds? Typically, OOPM may have separate in-network and out-of-network accumulators. But the plan says "Out-of-pocket maximum: Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000." It does not say whether they accumulate separately. The prompt's glossary says "Accumulator: the running year-to-date total of a member's deductible or OOPM." It doesn't mention separate IN/OON OOPM balances. However, the plan lists separate amounts. How to reconcile?
Let's examine the plan document carefully:
Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the
allowed amount for covered services for the remainder of the plan year.
It does not mention a family out-of-network OOPM. And it doesn't explicitly state whether in-network and out-of-network OOPM credits accumulate to a single balance or separate balances. For deductible, it explicitly says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." It does NOT say the same for OOPM. So perhaps OOPM accumulators are separate: one for in-network, one for out-of-network? But the prompt says "A member's own accumulator and the family accumulator both move on every claim that generates cost share." It doesn't specify separate. However, the plan document is the governing document. Since it explicitly calls out a single balance for deductible, and doesn't for OOPM, maybe OOPM is also a single balance? But then there are two thresholds: 6000 for IN, 12000 for OON. How would that work with a single balance? If a member has a single OOPM balance, the threshold would have to depend on the service being adjudicated. For example, if the balance is 7000, and they have an in-network service, they have not reached the 6000? Wait, 7000 > 6000, so they have exceeded the in-network OOPM. But if the balance is single, then for an out-of-network service, the threshold is 12000, so at 7000 they haven't reached it. That would mean the plan pays 100% for in-network but not for OON? That seems plausible. But typically, OOPM is the most you pay. If you have a single OOPM balance, and you've paid 7000, you've exceeded the in-network OOPM of 6000. For any in-network service, plan pays 100%. For OON, you still pay cost share until 12000. This is possible if the plan has a combined OOPM but separate thresholds per network. However, the plan says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It doesn't say "for the network type". It says "covered services". But OON services might not be covered or might be covered at a lower rate.
Alternatively, maybe there are separate OOPM accumulators: in-network OOPM and out-of-network OOPM. The plan lists individual (in-network) and individual (out-of-network). It might be that there are two separate accumulators. But the prompt's general rule says "A member's own accumulator and the family accumulator both move on every claim that generates cost share." That suggests one member accumulator and one family accumulator for each of deductible and OOPM. It doesn't say "accumulators". But the plan document's explicit language about a single deductible balance is strong. Since it didn't say the same for OOPM, but the general rule seems to treat them as singular, we need to decide.
Let's look at the family OOPM: 12000 (in-network). Individual OON OOPM: 12000. So the OON individual OOPM equals the family OOPM. If we treat OOPM as a single balance per member with threshold depending on network, then for A, after some claims, if A's OOPM balance reaches 6000, then for any in-network service, plan pays 100%. If A then has an OON service, since balance is 6000 < 12000, A still pays cost share. That seems consistent with the plan's listing of separate thresholds.
But is there a family OOPM for OON? Not listed. The family OOPM is 12000 (in-network). Does the family OOPM apply to OON? The plan doesn't say. It just says "Family (in-network) .................... 12000.00". It might be that the family OOPM only applies to in-network services, and OON has no family cap? But that seems unlikely; more likely the family OOPM is 12000 overall. However, the plan document specifically labels it in-network. Since the governing document says that, we should perhaps treat the family OOPM as 12000 for in-network only? But that would be weird because then OON services could cause family OOPM to exceed 12000 without cap? But the plan says "Once a member reaches the out-of-pocket maximum..." So the OOPM is per member, not per family? Actually there is a family OOPM. Once the family Ojson{
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"ending_deductible_b": 0.00,
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}
Grader detail
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}We need to adjudicate Claim 1, Claim 2, Claim 3, then Claim 4 in order, updating member and family accumulators after each. Then report components for Claim 4 and ending accumulators for A, B, and family.
Plan: Bluebonnet PPO 1500. Plan year 2026.
Key plan details:
- Deductible individual in-network: 1500.00
- Deductible family in-network: 3000.00
- Structure: EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
- Out-of-network individual deductible: 3000.00. Wait: plan says: "Out-of-network (individual) ............ 3000.00". And: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
Interpretation: For each member, there is one deductible accumulator that applies to both in-network and out-of-network services. The threshold used depends on network status? Let's parse precisely.
"In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
Plan lists:
- Deductible
Individual (in-network) ................ 1500.00
Family (in-network) .................... 3000.00
Structure .............................. EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
Out-of-network (individual) ............ 3000.00
So there is an in-network individual deductible of 1500, and an out-of-network individual deductible of 3000. Since credits accumulate to a single balance, presumably the member has one running total. If they receive in-network service, the threshold is 1500; if out-of-network, the threshold is 3000. However, since credits are single, satisfying the 1500 threshold for in-network also means they have 1500 toward the 3000 threshold for out-of-network. Wait, that would mean if they met in-network deductible, they still have 1500 more to go for out-of-network? But the plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." Actually the amounts above: individual in-network 1500, out-of-network individual 3000. So the threshold for in-network is 1500, out-of-network is 3000. The balance is the same.
But what about family? The plan lists family in-network 3000. Does it list family out-of-network? No. But perhaps the family deductible is only 3000, and since it's embedded, the family amount is measured against total family in-network? Or total family combined? Since the structure says "embedded — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Usually in embedded deductible, each individual has their own individual deductible. When any individual meets their individual deductible, coinsurance starts for that person. When the sum of all family members' deductible payments/credits reaches the family deductible, the family deductible is satisfied, and coinsurance starts for everyone (even those who haven't met their individual). But here because there is a single balance per member that applies to both in and out of network with different thresholds, interpreting family requires care.
Let's parse the "Structure" language: "EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
Given they mention "total family credits", that suggests all deductible credits across all members count toward the family total. The family amount is 3000 (in-network). The family deductible being satisfied means what? Typically under embedded, once family total reaches 3000, the deductible is considered satisfied for all members for the remainder of the year. But note the out-of-network individual threshold is 3000. Does the family OOPM have out-of-network? Plan says OOPM individual out-of-network 12000. Family OOPM in-network 12000. Wait there is no family out-of-network OOPM listed? It only lists:
Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year.
So family OOPM is only given as in-network 12000. Does out-of-network count toward family OOPM? The plan doesn't specify a family out-of-network OOPM distinct. Likely the family OOPM is 12000 overall for in-network, and individual OON OOPM is 12000. But the question asks for ending_family_oopm. How to handle OON OOP contributions toward family OOP? The plan doesn't mention family OOP for OON. However, since family OOP is presumably aggregate of all members' OOP. The plan says "Once a member reaches the out-of-pocket maximum the plan pays 100%..." That refers to member reaching their individual OOPM. The family OOPM is separate: Family (in-network) 12000. The phrasing might mean the family OOPM applies to in-network services, but out-of-network services count toward the individual OON OOPM of 12000. But do out-of-network member cost shares count toward family OOP? Usually, yes, family OOP includes all cost share across all members regardless of network, if not specified otherwise. But the plan document only lists "Family (in-network)". However the family OOPM is often the aggregated OOP total across in-network services? Let's inspect carefully.
The prompt says: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." That is about individual OOP. There is no explicit mention of family OOP triggering 100% for all. But family OOPM is a limit on aggregate family spending for in-network? Actually typical family OOP is the max the whole family pays. If family OOP is reached, all members are done paying cost share. Here the family OOPM is given as in-network 12000. In many plans, family OOPM is an aggregate cap on all members' OOP, including both in-network and out-of-network, but sometimes OON doesn't count. But the document specifically says "Family (in-network)". I need to be careful.
Given the harness likely expects a specific interpretation. Let's read the OOP section again:
Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year.
Notably, there is no "Family (out-of-network)". The harness may want us to assume family OOPM 12000 applies overall (maybe in-network only? But the prompt says "Family (in-network) 12000"). If a claim is out-of-network, does the member cost share count toward family OOP? The plan is silent. However, under "Copays do NOT credit the deductible. Copays always credit the out-of-pocket maximum." The phrase "the out-of-pocket maximum" ambiguous. Normally all member cost share counts toward the OOP maximum (both individual and family). The family OOP maximum is the aggregate of all members' cost share contributions.
Given the typical rule: Family OOPM includes all cost share amounts that count toward individual OOPMs. If an OON service accrues to individual OON OOPM, it should also accrue to family OOPM, unless the plan explicitly says family OOP is in-network only. But the family OOPM line says "Family (in-network)". Could that be interpreted as the family OOPM only considers in-network member cost share? If so, out-of-network cost share would not count toward family OOPM. But then what would "family total out-of-pocket" represent? It would be sum of in-network OOP only.
But the starting accumulators show:
Family total deductible 900.00, out-of-pocket 900.00. That came from A's accumulators only since B has 0. So the family totals are simply sum of individual accumulators. Starting family OOP is 900.00, which matches A's OOP (A has OON services presumably previously). If family OOP were in-network only, and A's prior 900 OOP came from OON, then family OOP wouldn't be 900. Since the starting family OOP is 900, that indicates family OOP sums all members' OOP regardless of network. Because A's 900 OOP likely came from OON (since A's deductible is 900 and OOP 900; under OON threshold 3000, they paid 900 deductible; OOP equals deductible so maybe no coinsurance yet). But family OOP total includes that 900. So family OOP is sum of individual OOP, including OON.
Similarly, family deductible total is 900, sum of individual deductibles (A 900 + B 0). Since A's deductible is single balance. For family deductible, is the family total the sum of each member's single deductible balance? Typically yes. But the family deductible amount threshold is 3000 (in-network). Does OON count toward family deductible? The plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." It doesn't explicitly say family counts OON. But the family total accumulator is defined as the sum of individual balances perhaps irrespective of network. Starting family deductible is 900. That's A's balance. So yes, the family deductible accumulator appears to be sum of members' deductible balances.
Now, the deductible satisfaction logic for embedded: Under embedded, an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
But since there's a single balance per member that counts toward both thresholds, we need to track for each claim whether the deductible is satisfied (i.e., the balance meets the relevant threshold for that service's network). For in-network, threshold is 1500 for individual, 3000 for family. For out-of-network, threshold is 3000 for individual. Does the family deductible have an out-of-network threshold? Not listed. Under the "single member deductible balance", the amount above (3000) is the threshold that balance is measured against when the service is out-of-network. Likely the family deductible threshold remains 3000 regardless of network, because they didn't specify a separate family OON deductible.
Wait, the plan says: "Out-of-network (individual) ............ 3000.00". It doesn't mention family OON. The "Structure .............................. EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." The family amount is 3000. So regardless of network, the family deductible is 3000. Since balances are single per member, family total is sum of balances.
Now I need to process the claims sequentially.
Starting accumulators (before Claim 1):
A: deductible balance 900.00 (single balance), out-of-pocket 900.00.
B: deductible balance 0.00, out-of-pocket 0.00.
Family total: deductible 900.00, out-of-pocket 900.00.
Note: Deductible balances count toward whichever threshold applies. A has 900 applied. Since A hasn't yet satisfied individual in-network (1500) nor individual out-of-network (3000). Family hasn't satisfied 3000.
Now Claim 1: 2026-05-05, A, OON specialist procedure, billed 4440, allowed 2400. Network: OON.
Service is specialist procedure. This is not an office visit (it's a procedure), so no copay. Member cost share is coinsurance after deductible for OON: 40% member / 60% plan.
Deductible is applied before coinsurance.
Since it's OON, threshold for A is 3000. A's current deductible balance is 900. Remaining to reach 3000: 2100.
Allowed amount is 2400.
First, deductible is applied: the lesser of allowed amount and remaining deductible. But we need to consider both individual and family remainders? Under embedded deductible, a member's deductible is satisfied by the lesser of their individual remainder and the family remainder. Yes, the family rule says: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
Wait, that general rule for the task family says: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
Let's parse this carefully. In an embedded deductible, for each claim, we compare the member's remaining individual deductible (threshold - individual balance) and the family's remaining deductible (threshold - family total balance). The amount applied to deductible is limited by whichever remainder is less? Or the member's deductible is considered satisfied when the lesser of the two remainders reaches zero? Actually the phrase "a member's deductible is satisfied by the lesser of their individual remainder and the family remainder" is ambiguous.
Let's interpret: Under embedded, when determining how much deductible to apply to a claim for a member, the deductible is satisfied based on the lesser of the member's individual remaining deductible and the family's remaining deductible. For example, if the family remaining deductible is smaller than the individual remaining deductible, the member cannot have more deductible applied than the family remainder, because once family deductible is met, deductible is satisfied for all. Wait, that would mean if the family remainder is $100, and the member still owes $500 individual, on the next claim only $100 can be applied to deductible, and then the family deductible is satisfied, so the rest of that claim goes to coinsurance. At that point, the individual deductible might also be satisfied because the family total reached the family threshold? Actually embedded means there are two ways to satisfy the deductible: either individual balance reaches individual threshold (1500/3000), or family total reaches family threshold (3000). Once either condition is met for that member, they are in coinsurance. But if the family threshold is reached first, all members are considered to have satisfied their deductible even if their individual balance is below individual threshold.
Thus, for each claim, we need to calculate how much of the allowed amount is subject to deductible, considering:
1. Member's individual remaining deductible (threshold_member - member_balance)
2. Family remaining deductible (threshold_family - family_balance)
3. The deductible applied is limited by the lesser of those two remainders? Actually if the family remaining is lower, the family deductible will be exhausted by this claim. Once family deductible is exhausted, the member's deductible is satisfied for the purpose of this claim after the family portion is used. But does the individual balance continue to increase beyond the individual threshold? No, it stops at the individual threshold. But under embedded, the individual deductible can be "satisfied" because the family threshold was met. But the wording "satisfied by the lesser of their individual remainder and the family remainder" means: Deductible is considered satisfied when the amount needed to satisfy the deductible is the lesser of the two remainders. Let's think.
Suppose member A has individual remaining = 600 (i.e., balance 900, threshold 1500), family remaining = 2100 (family balance 900, threshold 3000). Lesser is 600. So A's deductible is satisfied after 600 more is applied (individual threshold reached). After that, coinsurance begins for A. Family remaining would then be 1500. That seems normal.
Suppose member B has individual remaining = 1500 (balance 0), family remaining = 1500 (family balance 1500 after A satisfied). B then incurs a claim of 2000. Individual remaining = 1500, family remaining = 1500. Lesser is 1500. So B's deductible is satisfied after 1500 applied. Family deductible also met. Both satisfied.
Suppose A has individual remaining = 600, family remaining = 200. Then lesser is 200. That means only 200 of deductible can be applied before the family deductible is satisfied, even though A hasn't reached individual threshold. After 200 applied, family total reaches 3000 (deductible satisfied for all). Then A's claim would go to coinsurance for the rest, even though A's individual balance is only 1100 (if started at 900). This is how embedded works: family cap overrides.
But wait, in that scenario the family deductible is 3000 and embedded means once the family total hits 3000, everyone is done with deductible. So the amount needed to satisfy the family is 200. The amount needed to satisfy A individually is 600. Because the family limit is lower, only 200 more deductible is taken from A's claim; then the rest is coinsurance. A's individual deductible is considered satisfied because the family threshold was reached (the plan says "whichever comes first").
But then A's individual balance would be 1100, which is less than the individual threshold (1500). Can A later have more deductible applied? No, because the family deductible is already satisfied, so no further deductible applies for any member. Thus A's individual deductible is effectively satisfied by virtue of the family limit. This is standard.
Thus, the amount of deductible applied to a claim is the lesser of:
- The portion of the allowed amount needed to satisfy the member's individual remaining deductible (subject to allowed amount)
- The portion needed to satisfy the family remaining deductible (subject to allowed amount)
But also limited by the allowed amount.
Actually we need to compute the deductible applied as: min(allowed_amount, min(individual_remaining, family_remaining)). Then if there is remaining allowed amount after deductible, apply coinsurance (subject to OOP caps). However, after the deductible phase ends for that claim (either because individual or family satisfied mid-claim), coinsurance applies to the rest. But if allowed amount is less than both remainders, the entire allowed amount goes to deductible and no coinsurance.
But be careful: If individual remaining is less than family remaining, then after applying individual remaining as deductible, the member's individual deductible is satisfied. Family remaining is decreased by that same amount. For the remainder of the claim (allowed amount minus deductible applied), coinsurance applies.
If family remaining is less than individual remaining, then after applying family remaining as deductible, the family deductible is satisfied (and thus member's deductible is satisfied). Family remaining becomes zero. For the rest of the claim, coinsurance applies. The individual balance increases by the family remaining amount, but stops there (maybe not reaching individual threshold). Since family satisfied, no further deductible for anyone.
The prompt's rule: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." This aligns with the above: the deductible is satisfied when the lesser of the two is exhausted. So the amount applied to deductible from the claim is exactly that lesser amount (or up to allowed amount). If allowed amount is larger than that lesser amount, then the lesser amount is deductible, and the rest is coinsurance. If alloweGrader detail
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}Reasoning · 16,609 tokens
We need to adjudicate Claims 1 through 4 in order, updating accumulators after each claim. Then report the components for Claim 4 and the ending accumulators for A, B, and family after Claim 4.
The plan document: Bluebonnet PPO 1500.
Plan year 2026.
Deductible:
- Individual in-network: 1500.00
- Family in-network: 3000.00
- Structure: EMBEDDED — individual satisfies individual on their own; family deductible is also satisfied once total family credits reach family amount, whichever comes first.
- Out-of-network (individual): 3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network.
So there is a single deductible balance per member that includes both in-network and out-of-network amounts. The threshold for that balance depends on whether the service is in-network or out-of-network? Let's parse: "The amount above is the threshold that balance is measured against when the service is out-of-network." This likely means the out-of-network individual threshold is 3000.00, while in-network individual threshold is 1500.00. But the balance is the same single balance. So if a member has both in-network and out-of-network claims, the same balance accumulates, but if they have an out-of-network service, the threshold used is 3000.00; if they have an in-network service, the threshold used is 1500.00. However, the family threshold is 3000.00 for in-network? Actually the family deductible is listed under Deductible with only in-network? Wait: "Family (in-network) 3000.00". Out-of-network family deductible is not listed. Hmm. The document says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." The "amount above" refers to "Out-of-network (individual) 3000.00". So for an out-of-network service, the individual deductible threshold is 3000.00. For in-network, it's 1500.00.
But what about family? The family deductible is 3000.00 in-network. Does out-of-network have a separate family deductible? Not listed. Maybe the family deductible threshold is 3000.00 regardless? Or perhaps the family deductible is also measured against the family balance, which includes both in and out-of-network. The document doesn't specify an out-of-network family deductible amount, so likely the family deductible threshold is 3000.00 for all services? Let's think. Usually, family deductible might be the same for in and out, but here they only list in-network individual and family, and out-of-network individual. It says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." The "amount above" is singular; so for the member balance, the threshold is 3000 when service is OON. For family, maybe the threshold is 3000 regardless? Or maybe the family deductible also uses the OON threshold when service is OON? But the document doesn't state an out-of-network family deductible. Since the plan document governs, and it doesn't specify, but we have to adjudicate. Let's read carefully:
"Deductible
Individual (in-network) ................ 1500.00
Family (in-network) .................... 3000.00
Structure .............................. EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first.
Out-of-network (individual) ............ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So the family deductible is 3000.00. The structure is embedded. The family deductible is satisfied once total family credits reach the family amount. The credits are from all members? The family total deductible accumulator starts at 900.00. That means total family credits so far are 900.00.
Wait, how does the embedded family deductible work with a single member balance that includes both in-network and out-of-network? For embedded deductible: each individual must satisfy their individual deductible, but the family deductible can also be satisfied by the sum of all family members' deductible credits. The document says "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." That means for each claim, we need to decide if the deductible is satisfied for that member at the individual level or at the family level.
But there is a nuance: the family deductible is 3000.00. The individual in-network is 1500.00, out-of-network individual is 3000.00. Since credits accumulate to a single balance per member, an out-of-network service sees the member's balance against 3000.00. For in-network, against 1500.00. However, for family, what is the threshold? The document does not differentiate family by network. So family deductible threshold is 3000.00 regardless. But we need to see how the credits apply to family. The family accumulator is the sum of all members' deductible credits? Or is it a separate accumulator? The prompt says: "A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
This is a rule from the prompt family, not the plan document. Let's read that rule: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." This means when determining how much deductible applies to a claim for a member, we compare the remaining individual deductible for that member and the remaining family deductible, and apply the lesser of those two remainders as the deductible for that claim. After that, both the individual and family deductibles are reduced by the amount applied.
Wait, is that standard? In embedded deductibles, each member has their own individual deductible. The family deductible is also a bucket. If a member meets their individual deductible, the plan starts paying for them even if the family deductible isn't met. But if the family deductible is met before any individual meets theirs, then all members are considered to have met their deductible. The "lesser of the two remainders" rule is a way to model this: if family remaining is less than individual remaining, then the family deductible is met first, and the amount applied is the family remainder (which is less), meaning the member's deductible is considered satisfied once the family bucket is drained. However, usually in embedded, the individual and family deductibles operate side by side: the amount the member pays toward deductible counts toward both individual and family. The plan pays once the individual deductible is met OR once the family deductible is met (whichever comes first). So the cost share begins when the individual remaining is 0 OR the family remaining is 0. But how much deductible applies to a specific claim? It depends on the remaining amounts. The "lesser of the two remainders" is a specific instruction from the prompt family rules. Let's parse the exact wording: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
This is from the task family rules. The plan document says: "Structure .............................. EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first."
So we need to combine these. The plan document states the concept, but the task family gives the operational rule: the deductible applied to a claim is the lesser of the individual remainder and the family remainder. Actually, let's read the task family rule again carefully:
"A member's own accumulator and the family accumulator both move on every claim that generates cost share. Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder."
This means: For a given claim, the amount that goes toward deductible (i.e., the deductible_applied) is capped by both the member's remaining individual deductible and the family's remaining deductible. But actually, it says "satisfied by the lesser of their individual remainder and the family remainder." This could mean: If a member has $1000 remaining individual and family has $500 remaining, then the deductible that can be satisfied on this claim is limited to $500 (the family remainder). Once $500 is applied, the family deductible is now $0, so the plan starts paying for all family members (since family deductible is met). The member's individual remaining would also be reduced by $500? Or would it be reduced to $0 because the family deductible being met means the member's deductible is considered satisfied? The prompt says "a member's own accumulator and the family accumulator both move on every claim that generates cost share." So both are reduced by the amount of cost share that is applied to deductible.
Wait, but the prompt also says: "Under an embedded structure a member's deductible is satisfied by the lesser of their individual remainder and the family remainder." Let's think about a typical embedded deductible scenario: Suppose family deductible is $3000, individual is $1500. Member A has $900 already credited. Member B has $0. Family has $900. Now A has an allowed amount of $2400 OON. A's individual remaining for OON is $3000 - $900 = $2100. Family remaining is $3000 - $900 = $2100. The lesser is $2100. So deductible applied is up to $2100. After applying $2100, A's individual remaining becomes $0 (since 2100-2100=0). Family remaining becomes $0 (2100-2100=0). Then any remaining amount is subject to coinsurance. But wait, if family remaining is $2100, and we apply $2100 to family, the family deductible is met. But if we apply $2100 to A's individual, A's individual OON deductible is $3000, so after $900+$2100 = $3000, A's individual is met. So both are met simultaneously here.
But what if family remaining was less than individual remaining? E.g., family remaining $500, individual remaining $1000. Then the lesser is $500. So only $500 of deductible can be applied to this claim. After that, family deductible is $0, so plan pays for everyone. Does the individual's remaining get reduced by $500? The prompt says both move. So A's individual accumulator would increase by $500, leaving $500 remaining. But since family is met, does the plan pay 100% after deductible? Wait, the plan says coinsurance applies after deductible. If the family deductible is met, the member's deductible is satisfied (the family trigger). But the prompt's operational rule says the member's deductible is satisfied by the lesser of the two remainders. That implies that if the family remainder is the lesser, then the deductible is satisfied once that amount is reached, even if the individual hasn't reached their individual threshold. So the amount applied to deductible is the family remainder, and then after that, the plan pays according to coinsurance. The individual accumulator would still be increased by that amount? Or does the individual accumulator get set to its threshold? The wording is ambiguous.
However, the prompt says: "A member's own accumulator and the family accumulator both move on every claim that generates cost share." So both increase by the amount of cost share that is applied to deductible. So if we apply $500 deductible, both A's individual deductible accumulator and family accumulator increase by $500. Then family reaches $3000, A's individual reaches $900+$500=$1400 (still below $1500). But since family is met, A's deductible is considered satisfied for future claims. But for this claim, we applied $500 deductible. After that, the remaining allowed amount is subject to coinsurance. Does the member also have to pay coinsurance on the remainder? Yes.
But wait: if family is met, then for any future claim, the deductible is already satisfied. For this claim, we only applied $500 toward deductible, and the rest is coinsurance (or copay if applicable).
But there is a nuance: the plan document says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." This means the member's deductible balance is a single number, not separate for in and out. The threshold used depends on the network of the current service. So for Claim 1 (OON), we use threshold 3000.00. For Claim 3 (INN), we use threshold 1500.00. But the balance itself is the same.
However, the family deductible is a single family balance. The plan document does not mention network-specific family deductible. So the family threshold is 3000.00 regardless.
Also, out-of-pocket maximums:
- Individual in-network: 6000.00
- Family in-network: 12000.00
- Individual out-of-network: 12000.00
- Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year.
The prompt says: "A member's own accumulator and the family accumulator both move on every claim that generates cost share." So OOPM also has individual and family accumulators. The OOPM family is 12000.00. There is no mention of OON family OOPM; only individual OON OOPM is 12000.00. The family OOPM is listed as "Family (in-network) 12000.00". But perhaps it's a general family OOPM? Or maybe OON services don't credit the family OOPM? The plan document says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It doesn't specify network for this statement. It also says OON individual OOPM is 12000.00. Family OOPM is in-network 12000.00. Does OON cost share count toward family OOPM? Usually, family OOPM includes all cost share from all members, regardless of network, unless specified otherwise. But the plan document says "Family (in-network) 12000.00". That might mean only in-network? Or it's the family OOPM for all services? Let's parse the exact text:
"Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year."
It lists three thresholds: individual in-network, family in-network, individual out-of-network. It does not list family out-of-network. Does that mean there is no family out-of-pocket maximum for out-of-network? Or that the family OOPM is 12000 regardless? In many plans, the family OOPM is the sum of in-network and out-of-network cost sharing, but here they specifically label it as in-network. The prompt's family rule says "A member's own accumulator and the family accumulator both move on every claim that generates cost share." It doesn't distinguish network for the family accumulator. So we should probably treat the family OOPM as 12000 for all cost share, unless the plan document says otherwise. But the plan document labels it as "Family (in-network)". Does that mean out-of-network cost share does not credit the family OOPM? That would be unusual but possible in a synthetic plan. However, the prompt family rule says "both move on every claim that generates cost share." So likely the family OOPM moves regardless of network. The plan document's labeling might just be indicating the primary family OOPM, but since it doesn't mention OON family OOPM, maybe it's the same. Alternatively, maybe OON cost share only credits the individual OON OOPM, not the family OOPM. But the task family rule explicitly says family accumulator moves on every claim. So we must increase the family OOPM accumulator for all claims.
Also, the OOPM family threshold is 12000.00. The prompt says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." This is about individual OOPM. There's no mention of family OOPM triggering 100% for all members, but that's a standard ACA feature: once family OOPM is met, the plan pays 100% for all family members. But the plan document doesn't explicitly state that. It only says "Once a member reaches the out-of-pocket maximum..." It doesn't say anything about family OOPM. So maybe the family OOPM is just a cap on the total family cost share, but does not trigger 100% plan payment for other members? However, the prompt family rule says "A member's own accumulator and the family accumulator both move on every claim that generates cost share." It doesn't say family OOPM triggers anything. So maybe the family OOPM is just a cap, and once reached, cost share is zero for all members? Or maybe it's irrelevant except as a cap. But the required keys include ending_family_oopm, so we need to track it.
Let's also think about the OOPM for out-of-network: "Individual (out-of-network) 12000.00". Does that mean there is a separate OOPM accumulator for out-of-network? The plan document says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It doesn't mention separate OOPM buckets. But it lists separate amounts. Usually, a member has one OOPM balance that includes both in and out-of-network, but the threshold is the higher of the two? Or separate? In many plans, in-network and out-of-network have separate OOPMs. The plan document lists "Individual (in-network) 6000.00" and "Individual (out-of-network) 12000.00". This suggests there are two separate individual OOPM accumulators? Or perhaps the OOPM is network-specific: in-network cost share counts toward the in-network OOPM, out-of-network counts toward the out-of-network OOPM. However, the prompt family rule says "A member's own accumulator and the family accumulator both move on every claim that generates cost share." The singular "own accumulator" suggests one per member. But the plan document lists two. This is a point of ambiguity.
Let's re-read carefully: "Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year."
It doesn't explicitly say there are separate accumulators. But the presence of both an in-network and out-of-network individual OOPM suggests that maybe the threshold is 6000 for in-network and 12000 for out-of-network. However, the statement "Once a member reaches the out-of-pocket maximum" singular could refer to whichever is applicable. So if the member has in-network services, the threshold is 6000; if out-of-network, the threshold is 12000. But cost share from in-network and out-of-network might accumulate to the same balance? Or to separate balances? The plan document doesn't say they accumulate to a single balance (unlike deductible, which explicitly says so). For OOPM, it does not say they accumulate to a single balance. This could mean they are separate.
But the task family rule says: "A member's own accumulator json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}67DeepSeek V4 Pro · DeepSeek115.8s · 7,686 out | 16.5s · 2,400 out | 96.7s · 6,066 out
Reasoning · 7,535 tokens
We are asked to adjudicate a series of claims in order, each updating accumulators, and then report specifically for Claim 4 (the fourth claim, for A, out-of-network diagnostic study). Also report ending accumulators after all claims are processed.
We are given starting accumulators before claim 1:
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family deductible: 900.00, family OOPM: 900.00
Plan details:
- In-network deductible: individual 1500, family 3000, embedded.
- Out-of-network deductible: individual 3000 (but note: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." So there's one member-level deductible accumulator that gets credits from both in- and out-of-network services. The threshold for whether it is met depends on the network status of the service. For in-network, the threshold is 1500; for out-of-network, it's 3000. For family deductible, the family threshold for in-network is 3000, but for out-of-network? The plan document doesn't specify an out-of-network family deductible. It says "Family (in-network) 3000.00" and "Deductible Out-of-network (individual) 3000.00". No separate family OON deductible mentioned. It says: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." That applies to the individual-only. For family deductible, presumably it's the in-network family deductible amount that is used as the family threshold, and out-of-network claims also credit that same family accumulator? The document says "Family (in-network) 3000.00" under Deductible. There's no mention of a separate out-of-network family deductible. And it says: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." That's for member-level. For family, they likely use the same family deductible accumulator and threshold (3000) regardless of network? But the plan says "Family (in-network)" only. In many real plans, the family deductible for OON might be double, but here only in-network is specified. The document's wording: "Family (in-network) .................... 3000.00". It doesn't list an out-of-network family deductible. So I think the family deductible applies only for in-network services? However, the principle of embedded deductible: each member's own deductible credits also count towards the family deductible. For out-of-network services, those credits count toward the member's single deductible balance (which is measured against OON threshold 3000 for OON services). But do those credits also count toward the family deductible? The plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." That implies there is only one member balance, so credits from OON services also go to that balance. Does that balance also contribute to the family deductible? The family deductible is described only for in-network, but typically in an embedded plan, any member's deductible credits (from covered services) count toward the family deductible. I'd assume that OON services also count toward the family deductible accumulator, and the family deductible threshold is 3000 for in-network; but for OON services, the family deductible might not apply because family deductible is listed only under in-network. However, the plan does not explicitly say that OON services are excluded from family deductible accumulation. The plan says "Deductible: Individual (in-network) 1500.00, Family (in-network) 3000.00, Structure: EMBEDDED". It doesn't mention family out-of-network. In practice, many plans have a single family deductible that applies to both in and out-of-network, but with OON having a higher individual threshold. But here it's ambiguous. I'll look at the exact wording: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." So the SINGLE member deductible balance is used for both thresholds. That balance is increased by both in-network and out-of-network credits. Then, for a claim, if in-network, the plan checks if the member's deductible balance has met the in-network individual threshold (1500) and the family deductible (3000) as per embedded rules. If out-of-network, it checks if the member's balance has met the out-of-network individual threshold (3000) and presumably also the family deductible? But the family deductible is labeled "Family (in-network)", so maybe OON services don't need to meet family deductible? Or maybe the family deductible only applies for in-network services; for OON services, only individual deductible applies? That would be odd. Typically, the family deductible is an aggregate limit for the family, and if a member goes OON, the family deductible still applies but with a higher individual OON deductible. Since the plan document does not specify an OON family deductible, and calls the family deductible "in-network", it could mean that the family deductible only applies for in-network services. Out-of-network services might not count toward the family deductible and might only be subject to the individual OON deductible. But the phrase "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance" suggests that both types of claims credit the same member balance, which then counts toward the family deductible if they are in-network? That seems inconsistent. I'll check the rest of the plan: no mention of family OON deductible. I think the safest interpretation is that the family deductible amount applies only to in-network services. For out-of-network services, the member must satisfy the individual out-of-network deductible (3000) and the family deductible does not apply (or it's only the in-network family deductible that doesn't affect OON). However, the member deductible balance is a single balance that is credited with both in- and out-of-network claims. So when processing an OON claim, we consider the member's current deductible balance and check if it meets the individual OON threshold of 3000. Also, what about family OOPM? Family OOPM in-network is 12000, out-of-network individual OOPM is 12000. Again, family OOPM is only in-network. So OON claims might only count toward individual OOPM, not family OOPM? Need to interpret. I'll read the plan document literally: For deductible, it lists Individual (in-network) 1500, Family (in-network) 3000, Out-of-network (individual) 3000. So OON individual deductible is separate threshold, but the credits are pooled. For OOPM: Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. So OON OOPM per individual is 12000. There's no family OON OOPM. So likely OON services are only subject to the individual limits, not family limits. But the single member deductible balance and member OOPM balance might be separate? Or they might pool OOPM as well: "Copays always credit the out-of-pocket maximum." And OOPM for in-network individual is 6000, out-of-network individual is 12000. The plan doesn't say whether OON cost-sharing counts toward the in-network OOPM or just the OON OOPM. Typically, plans have separate OOPM accumulators for in-network and out-of-network. But here they list them separately, so likely they are separate tracks. However, the plan says: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It doesn't specify which OOPM, but likely it's the relevant one based on network. So for OON services, the member must reach the OON individual OOPM of 12000 for the plan to pay 100% for OON services. In-network OOPM is 6000 individual, 12000 family. So they are separate. Also, cost-sharing for OON services does not count toward in-network OOPM, probably. But does in-network cost-sharing count toward OON OOPM? Usually they are separate. So I'll assume separate OOPM accumulators: one for in-network (with individual and family limits), and one for out-of-network (individual only, since no family listed). But the plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance" but does NOT say that for OOPM. So OOPM accumulators are likely separate for in-network and out-of-network. The starting OOPM values are 900 for A, 0 for B, and family OOPM 900. Given that they started with these, they must be the in-network OOPM accumulators? The problem statement: "FAMILY ACCUMULATORS as of the moment before Claim 1 A (subscriber) deductible 900.00 out-of-pocket 900.00 B (spouse) deductible 0.00 out-of-pocket 0.00 Family total deductible 900.00 out-of-pocket 900.00". It doesn't specify in-net vs out-of-net for these accumulators. Presumably, the accumulators given are the ones that apply based on the service type, or they are the single member deductible balance (which is shared) and the OOPM could be the in-network OOPM (since family OOPM is listed). Since they only gave one set, likely the deductible accumulator is the single balance used for both, and the OOPM accumulator is the in-network OOPM (and maybe OON OOPM is separate and starts at 0 for A and B? They didn't give OON OOPM accumulators. The problem statement didn't specify any out-of-pocket accumulators for out-of-network. So we might need to infer that the given OOPM accumulators are the in-network ones, and for OON claims, we need to track a separate OON OOPM for each member. That seems messy. Alternatively, perhaps the plan has a single OOPM that applies regardless of network, with individual limits that differ by network. For example, a member's in-network OOPM is 6000, and any cost-sharing (including OON) counts toward that, but once they hit 6000, the plan pays 100% for in-network only, while for OON they still need to satisfy the 12000 OON limit. But typical PPACA plans have unified OOPM but OON can have higher limits. Actually, the out-of-pocket maximum is usually a single total for all covered services, but plans can have a higher OOPM for out-of-network services. The member's total out-of-pocket spending counts toward the OOPM, but the OON limit is higher. So there could be one accumulator that is compared to both in-network and out-of-network thresholds. But the plan lists them as separate: Individual (in-network) 6000, Family (in-network) 12000, Individual (out-of-network) 12000. That suggests that the in-network OOPM (6000 individual, 12000 family) is a separate limit that only in-network cost-sharing counts toward, and the OON OOPM (12000 individual) is a separate limit that only OON cost-sharing counts toward. That would mean we need to track two sets of OOPM accumulators: one for in-network spending per member and family, and one for out-of-network spending per member (maybe no family). The problem statement gave initial OOPM for A=900, B=0, family=900. These likely refer to the in-network OOPM accumulators, as the family OOPM is only in-network. So for OON claims, we may need to track a separate OON OOPM accumulator for each member, starting at 0. That seems like a lot to infer. Let's look for clues in the plan document: "Copays always credit the out-of-pocket maximum." Which OOPM? Probably the one relevant to the service's network. So a copay for an in-network visit credits the in-network OOPM; an OON service may not have copays but if it did, it would credit OON OOPM. The document doesn't explicitly say OOPM accumulators are separate, but it lists separate limits. I think the safe approach is: deductible is a single accumulator per member (and family), with different thresholds based on network. OOPM is separate per network type (in-network OOPM accumulator per member/family, and out-of-network OOPM accumulator per individual, no family). The given initial accumulators include a family OOPM, so that must be the in-network OOPM accumulator for family. So A's in-network OOPM is 900, B's is 0, and family in-network OOPM is 900. Out-of-network OOPM for A and B start at 0. I'll adopt that.
Now process claims.
Claim 1: 2026-05-05, A, out-of-network specialist procedure, OON, billed 4440, allowed 2400.
Network: out-of-network. So subject to deductible (individual OON threshold 3000) and coinsurance 40% member after deductible. Also, since OON, there may be no family deductible threshold? I'll assume family deductible does not apply for OON services; only individual OON deductible. But the single member deductible balance is used. So A's current deductible balance is 900 (from starting). Need to see if he's met the OON deductible threshold of 3000. He has only 900, so he must pay more until his deductible balance reaches 3000. For OON, the deductible threshold is 3000. So he needs to apply the allowed amount toward his deductible balance until it hits 3000. He currently has 900, remaining to meet OON deductible: 3000 - 900 = 2100. So of the 2400 allowed, 2100 will go to deductible, leaving 300 to be subject to coinsurance. But wait: the plan says "The amount above is the threshold that balance is measured against when the service is out-of-network." So if the member's deductible balance is < 3000, the plan won't pay anything until the deductible balance reaches 3000. So on this claim, the member pays the allowed amount up to the amount that brings his deductible balance to 3000. That would be 2100 deductible, then coinsurance on the remaining 300. Member coinsurance 40% of 300 = 120. So total member responsibility = 2100 + 120 = 2220. Plan pays the rest: allowed - member = 2400 - 2220 = 180? Actually plan pays 60% of the 300 = 180. So plan paid = 180. But check: if the member has already accumulated 900 deductible balance, then after applying 2100, his new deductible balance becomes 3000, meeting the OON threshold. Then coinsurance on the 300. So member responsibility = deductible applied 2100 + coinsurance 120 = 2220. Plan paid = 180. But is the allowed amount limited by OON? The plan says member cost share is from allowed amount; balance billing above allowed is not member responsibility for in-network, but for out-of-network, they can balance bill. The question doesn't ask about balance billing, only member_responsibility and plan_paid from the allowed amount. So that's fine.
Now, what about accumulators? Deductible: the member's deductible balance increases by the amount of allowed that was applied to deductible. The plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." So the member's single deductible balance is increased by the amount that counts toward deductible. For this claim, the amount that goes to deductible is 2100. After claim 1, A's deductible balance = 900 + 2100 = 3000. The family deductible also accumulates: since the plan has embedded structure, and any member's deductible credits also go toward the family deductible. Does OON claim's deductible credit count toward family deductible? The family deductible is labeled "Family (in-network)". It doesn't explicitly say OON credits count toward family deductible. But the single member deductible balance is the same for both. The family deductible threshold is only for in-network services. However, if OON credits also credit the family deductible accumulator, then the family deductible balance would increase by the same amount. Given the "SINGLE member deductible balance", and the embedded structure, likely all deductible credits (in- and out-of-network) count toward both the member's balance and the family balance. The family deductible is a pooled accumulator. I'll assume that OON deductible credits also count toward the family deductible. Because otherwise, the phrase "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance" suggests that the member balance is shared, but the family balance might also be shared? I think it's typical that the family deductible accumulates from all covered expenses regardless of network. The plan doesn't say OON services are excluded from family deductible. The label "Family (in-network)" might just mean the family deductible amount applies only to in-network services, but the accumulation of credits might still happen from OON. The confusion: I need to decide. Let's read the plan again: "Deductible Individual (in-network) ................ 1500.00 Family (in-network) .................... 3000.00 Structure EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first. Out-of-network (individual) ............ 3000.00 In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." It does not mention an out-of-network family deductible. So for a claim that is out-of-network, the family deductible might not be considered; i.e., only the individual OON deductible matters, and the family deductible does not need to be met for OON claims. But the phrase "total family credits" implies that credits from all family members count toward the family deductible. It doesn't specify in-network only. So I think the family deductible accumulator is single, and credits from any claim (in or out) apply to it. The threshold for the family deductible is 3000, but that threshold likely only matters for in-network claims. For out-of-network claims, the family deductible threshold is irrelevant because the OON individual deductible is higher (3000). However, for an in-network claim, the member must have met both the individual in-network deductible (1500) and the family deductible (3000) in an embedded way. So OON claims would increase both the member's balance and the family balance. I'll go with that: family deductible accumulates from all claims. Then after claim 1, family deductible balance becomes starting 900 + 2100 = 3000. So family deductible is met.
OOPM: On claim 1, member cost-sharing (2220) counts toward OOPM. But which OOPM? For out-of-network services, there is an individual OON OOPM of 12000. I think the member's OON OOPM accumulator is separate from the in-network one. So we need to track two OOPM per member: in-network OOPM and out-of-network OOPM. Then the family OOPM is only for in-network. So for claim 1, A's OON OOPM accumulator increases by 2220. Starting OON OOPM for A was presumably 0. So after claim 1, A's OON OOPM = 2220. In-network OOPM for A remains 900. Family OOPM (in-network) remains 900. Also, does OON cost-sharing count toward the in-network OOPM? Typically no, separate. So no change to in-network OOPM.
Now claim 2: 2026-05-21, B (spouse), in-network outpatient imaging, allowed 1300. In-network. So subject to in-network rules: deductible (individual 1500, family 3000), coinsurance 20% after deductible. Copay? Not applicable; it's imaging, not an office visit. So it goes to deductible and coinsurance.
Current accumulators:
- A deductible balance: 3000 (after claim1)
- B deductible balance: 0 (starting)
- Family deductible balance: 3000 (already met)
- A in-network OOPM: 900
- A out-of-network OOPM: 2220
- B in-network OOPM: 0
- B out-of-network OOPM: 0 (assume)
- Family OOPM (in-network): 900
For claim 2, B is the member, in-network. Since family deductible is already met (3000), the family deductible condition is satisfied. B's individual in-network deductible is 1500. B has 0 so far. So B must satisfy his individual deductible up to 1500. However, because of embedded structure, oncjson{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 1520.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 1520,
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": true,
"abstained": false
}Reasoning · 2,250 tokens
We are given a family plan with embedded deductible. Starting accumulators before Claim 1:
A: ded 900, OOP 900
B: ded 0, OOP 0
Family: ded 900, OOP 900
Plan details:
- Deductible: individual in-network 1500, family 3000, embedded. Out-of-network individual 3000, but IN and OON deductible credits accumulate to a SINGLE member deductible balance. The threshold to be measured against is the OON deductible when service is OON? The plan document says: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." So the individual has a single running deductible balance (accumulated credits) that counts toward both. The deductible threshold for in-network is 1500, for out-of-network is 3000. That means when the service is OON, we look at the member's accumulated deductible credits (from both IN and OON) and see if it meets the OON deductible (3000). For in-network, we see if it meets 1500. Copays do not credit deductible.
- Coinsurance after deductible: IN 20% member, OON 40% member.
- Copays for office visits etc, but claims here are procedures/imaging/etc. So no copay applies unless specifically mentioned. The claims: Claim 1 OON specialist procedure, Claim 2 IN outpatient imaging, Claim 3 IN follow-up procedure, Claim 4 OON diagnostic study. No office visit, so no copay. These are subject to deductible and coinsurance.
- OOPM: individual IN 6000, family 12000, individual OON 12000. OOPM includes deductible, coinsurance, copays. Copays credit OOPM, deductibles credit OOPM. So OOPM is total member cost share paid.
We need to adjudicate Claim 1, 2, 3 in order, updating accumulators, then for Claim 4 report member responsibility, plan paid, deductible_applied, copay_amount (0 likely), coinsurance_amount, and ending accumulators for A, B, and family after Claim 4.
First, Claim 1 (2026-05-05, A, OON specialist procedure, allowed 2400.00). A starting ded=900, OOP=900. OON service: deductible threshold is OON deductible = 3000. A's deductible balance is 900. Remaining deductible to satisfy OON threshold: 3000 - 900 = 2100. So A must meet 2100 more before coinsurance. Allowed amount 2400. Deductible applied = min(2400, remaining ded) = min(2400,2100)=2100. So 2100 goes to deductible. Then remaining allowed 2400-2100=300 is subject to coinsurance. Coinsurance OON: 40% member, so member coinsurance = 300 * 0.40 = 120.00. Total member responsibility: deductible 2100 + coinsurance 120 = 2220.00. Plan paid = allowed - member responsibility = 2400 - 2220 = 180.00.
Update accumulators: A's ded increases by 2100 => 900+2100=3000. A's OOP increases by total member responsibility 2220 => 900+2220=3120. Family ded increases by 2100 (since A's ded credit goes to family) => 900+2100=3000. Family OOP increases by 2220 => 900+2220=3120. B unchanged.
After Claim 1:
A: ded 3000, OOP 3120
B: ded 0, OOP 0
Family: ded 3000, OOP 3120.
Check family deductible: 3000, so family deductible is met. Also, individual OON deductible satisfied for A (since 3000 = 3000). For subsequent OON services, A will only pay coinsurance. For IN services, A's deductible threshold is 1500, but his deductible balance is 3000 > 1500, so IN deductible is also fully satisfied. Indeed, for embedded, individual deductible is 1500, and since he has 3000 in ded, he's satisfied. Also family ded is 3000, so every member has ded satisfied.
Next, Claim 2 (2026-05-21, B, IN outpatient imaging, allowed 1300). B starting ded 0. But family ded already met at 3000? The embedded rule: individual deductible is 1500, family deductible is 3000. If family deductible is met before an individual meets his own, does that mean B's individual deductible is considered satisfied? Yes, because embedded means that once the family deductible is reached, all family members' deductibles are considered satisfied for the rest of the year. The family ded is 3000, and after Claim 1 family ded hit 3000. So B's individual deductible is effectively satisfied. So for B's claim, deductible applied = 0. Coinsurance: IN 20% member. Allowed 1300. So member coinsurance = 1300 * 0.20 = 260.00. No copay. Member responsibility = 260. Plan paid = 1300 - 260 = 1040.
Update: B's ded stays 0 (since no deductible applied). B's OOP increases by 260 => 0+260=260. Family ded unchanged (already 3000). Family OOP increases by 260 => 3120+260=3380.
After Claim 2:
A: ded 3000, OOP 3120
B: ded 0, OOP 260
Family: ded 3000, OOP 3380.
Claim 3 (2026-06-14, A, IN follow-up procedure, allowed 1800). A already met ded (both IN and OON thresholds). So deductible applied = 0. Coinsurance IN 20% => member coinsurance = 1800 * 0.20 = 360. Member responsibility = 360. Plan paid = 1800 - 360 = 1440.
Update: A's OOP increases by 360 => 3120+360=3480. A's ded unchanged. Family OOP increases by 360 => 3380+360=3740. B unchanged.
After Claim 3:
A: ded 3000, OOP 3480
B: ded 0, OOP 260
Family: ded 3000, OOP 3740.
Now Claim 4 (2026-07-08, A, OON diagnostic study, allowed 1600). A's OOP currently 3480. OON OOP max is 12000 for individual. Family OOP max 12000. A's OON out-of-pocket maximum is 12000, so not yet reached. Deductible: A fully satisfied, so deductible applied = 0. Coinsurance OON 40% => member coinsurance = 1600 * 0.40 = 640.00. So member responsibility = 640. Plan paid = 1600 - 640 = 960.
But check if A hits OOP max: after adding 640, A's OOP becomes 3480+640=4120, still under 12000.
Now we need the components for Claim 4:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
Now ending accumulators after Claim 4:
For A: deductible 3000.00, OOPM 4120.00 (from 3480+640)
For B: deductible 0.00, OOPM 260.00
Family deductible: 3000.00 (unchanged, already at max)
Family OOPM: 3740+640=4380.00
Double-check family OOPM: total family OOP after Claim 3 was 3740, add A's 640 = 4380. So:
ending_deductible_a: 3000.00
ending_oopm_a: 4120.00
ending_deductible_b: 0.00
ending_oopm_b: 260.00
ending_family_deductible: 3000.00
ending_family_oopm: 4380.00
Now confirm: For Claim 2, B's coinsurance is 20% of 1300 = 260, but did we account for the fact that family deductible was already met? Yes, embedded, so family deductible met means all members' deductibles are satisfied. So B's claim goes straight to coinsurance. That seems correct.
Check Claim 1: OON specialist procedure. The coinsurance for OON is 40% after deductible. Our calculation: allowed 2400, ded remaining to reach 3000 is 2100, so 2100 to ded, leaving 300 for coinsurance at 40% = 120. Total member cost 2220. That seems correct. Also check if there's any copay? Procedure, not office visit, so no.
Check Claim 4: OON diagnostic study, allowed 1600. A already met OON deductible (3000) and IN (1500). So all deductible met, so deductible applied 0, coinsurance 40% of 1600 = 640. Correct.
Now double-check family OOPM accumulation: After Claim 1: A OOP 3120, family OOP 3120. Claim 2: B OOP increases 260, family OOP now 3380. Claim 3: A OOP increases 360, family OOP 3740. Claim 4: A OOP increases 640, family OOP 4380. Correct.
Also verify that OON deductible credits accumulate to a single member deductible balance, so A's ded balance after Claim 1 is 3000, which meets OON deductible. For IN, A's deductible threshold 1500, so after Claim 1, if A had an IN claim, it would have been satisfied even though his deductible balance is 3000, because threshold is only 1500. So Claim 3 correctly had no deductible applied. All good.
Now output JSON with the required keys.json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 5,916 tokens
We are asked to adjudicate claims in order, updating accumulators for each member and family. Plan is Bluebonnet PPO 1500, synthetic, with embedded deductible. Family deductible is $3000, family OOPM $12000. Individual in-network deductible $1500, OOPM $6000. Out-of-network individual deductible $3000, OOPM $12000. Copays don't credit deductible, but credit OOPM. Deductible credits for in-network and out-of-network accumulate to a single member deductible balance; the threshold is $1500 for in-network, $3000 for out-of-network. So for out-of-network, member must satisfy the $3000 deductible before coinsurance kicks in; in-network deductible threshold is $1500. The single balance accumulates from both in- and out-of-network claims. So if a member has already paid some deductible from in-network claims, that counts toward the out-of-network deductible too. The text: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network." So the member deductible balance (accumulator) is compared against whichever threshold applies (in-network $1500, out-of-network $3000). So for an out-of-network claim, the member must satisfy the out-of-network threshold of $3000. But the accumulated balance includes all deductible payments. So we need to track a single "deductible accumulator" for each member, but then when we process a claim we check: if in-network, deductible remaining = max(0, 1500 - accumulator); if out-of-network, deductible remaining = max(0, 3000 - accumulator). Actually: "the amount above is the threshold that balance is measured against when the service is out-of-network." Means out-of-network deductible is $3000. So the remaining deductible for an out-of-network claim is $3000 minus the member's year-to-date deductible credits from all sources. So if member has already accumulated $900 from in-network, then for out-of-network they still need $2100 to reach $3000 threshold. But note: The plan document says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." That line suggests they share a single accumulator, not two separate ones. So the member has one deductible accumulator. The threshold for satisfying the deductible depends on network status of the service. So we'll track one deductible amount per member, and then apply the appropriate threshold when processing a claim.
Similarly, OOPM: individual in-network OOPM $6000, out-of-network $12000. But there's a single OOPM accumulator? The document says: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for the remainder of the plan year." It does not explicitly say the OOPM accumulations are separate or combined. Typically, in many plans, there is a single OOPM accumulator that applies to both in- and out-of-network, with higher limits for out-of-network. Here, they give separate individual in-network OOPM $6000 and out-of-network $12000. Likely, the OOPM is tracked separately per network? The document says: "Individual (in-network) ... 6000.00 ... Individual (out-of-network) ... 12000.00". It doesn't specify a combined accumulator. However, the phrase "copays always credit the out-of-pocket maximum" without specifying which. Usually, there is an embedded OOPM structure: the member's OOPM for in-network services is $6000, but all cost-sharing (including copays, coinsurance, deductible) for covered services count toward both in-network and out-of-network OOPMs. But if the member sees out-of-network providers, the out-of-network OOPM is higher ($12000). Often, the plan will have a single OOPM accumulator that applies to both, but when out-of-network services are used, the higher limit applies. But the plan document here provides separate numbers and says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services". I think the intended interpretation is: there is a single OOPM balance, but the cap depends on the network: for in-network services, cost-sharing stops when the member's total OOP spending reaches $6000; for out-of-network, it stops at $12000. However, it could be interpreted as two separate accumulators. Given typical payer logic, it's more common to have a single member OOPM accumulator and the applicable limit depends on the service's network. If the member's total cost-sharing (from all services) reaches the in-network OOP max, then in-network services are covered 100%. Out-of-network may have a separate, higher OOPM. But they often are separate. The document lists separate individual OOPM for in-network and out-of-network, so likely they are tracked separately. But then how do copays and deductible payments for in-network count toward out-of-network OOPM? Usually, all cost-sharing (including deductible, coinsurance, copays) for covered services count toward the out-of-pocket maximum, but the out-of-network OOPM is separate and only out-of-network cost-sharing applies to it. However, the document says: "Copays always credit the out-of-pocket maximum." Not specifying which, but likely both. In many real plans, there is a combined OOPM that includes both in- and out-of-network, but with a higher cap for out-of-network. I need to read carefully. The document: "Out-of-pocket maximum
Individual (in-network) ................ 6000.00
Family (in-network) .................... 12000.00
Individual (out-of-network) ............ 12000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of the
allowed amount for covered services for the remainder of the plan year." So "the out-of-pocket maximum" is singular; it says "the out-of-pocket maximum" not "the in-network out-of-pocket maximum". It says "Once a member reaches the out-of-pocket maximum...". This implies there is a single out-of-pocket maximum that applies, but there are different thresholds depending on network? Actually, it lists three numbers: individual in-network, family in-network, individual out-of-network. It doesn't say there is a combined one. It might be that the out-of-pocket maximum is $6000 for in-network and $12000 for out-of-network, but they are separate limits. The phrase "the out-of-pocket maximum" might refer to whichever applies. Given the ambiguity, I'll assume the typical interpretation: there are separate OOPM accumulators for in-network and out-of-network, and each tracks the cost-sharing for services in that network. Copays for in-network count toward in-network OOPM; copays for out-of-network? There's no out-of-network copay listed. For out-of-network, member pays deductible and coinsurance. So out-of-network cost-sharing (deductible and coinsurance) counts toward out-of-network OOPM. In-network cost-sharing (deductible, coinsurance, copays) counts toward in-network OOPM. But what about the family OOPM? Family in-network OOPM is $12000. Out-of-network OOPM is $12000 individual, but no family out-of-network OOPM listed. Possibly the family OOPM only applies to in-network. Or maybe the out-of-network OOPM is individual only, no family. I need to see if the prompts in other tasks in this family clarify. But here we are asked only for ending accumulators for A and B and family after claim 4. We'll need to compute each claim's cost-sharing and update accumulators accordingly.
First, we have starting accumulators:
A: deductible 900.00, OOPM 900.00 (presumably this is the in-network OOPM accumulator, but A's previous claims may have been in-network? Starting accumulators say A deductible 900, OOPM 900. Since copays credit OOPM but not deductible, the $900 could be from deductible payments or copays. Could be from an in-network claim with deductible. The family total deductible is 900 and family OOPM 900. So all previous claims were for A.
B: deductible 0, OOPM 0.
Now process claims:
Claim 1: A, out-of-network specialist procedure, allowed 2400, billed 4440. Out-of-network, so we use out-of-network deductible threshold $3000. A's current deductible accumulator = 900. So remaining deductible to satisfy out-of-network = max(0, 3000 - 900) = 2100. So the first 2100 of allowed amount goes to deductible, then coinsurance 40% member, 60% plan on the remainder. Allowed 2400, so deductible applied = min(remaining deductible, allowed) = min(2100, 2400) = 2100. Then remaining allowed after deductible = 2400 - 2100 = 300. Coinsurance: member pays 40% of 300 = 120. Plan pays 60% of 300 = 180. So total member responsibility = deductible 2100 + coinsurance 120 = 2220. No copay. Also, out-of-network: member may be balance billed for charges above allowed? The plan says "Member cost share is calculated from the ALLOWED amount. Amounts billed above the allowed amount are not the member's responsibility for in-network services." For out-of-network, balance billing is allowed typically. But here we only care about member responsibility as per plan, which is cost-sharing based on allowed amount. The billed amount is irrelevant. So member_responsibility = 2220, plan_paid = 180. This claim will update A's deductible accumulator: add 2100, so now A's deductible accumulator = 900+2100=3000. Note that this now equals $3000, which satisfies the out-of-network deductible for future claims, and also satisfies the $1500 in-network deductible (since it's >=1500). But the accumulator is a single balance, so A's deductible is now fully met for both networks? Actually, the threshold for in-network is $1500, and A has paid 3000, so remaining deductible for in-network is 0. For out-of-network, threshold is $3000, so remaining is 0. So deductible is satisfied.
Now update OOPM: We need to track separate OOPM accumulators for in-network and out-of-network? Starting OOPM 900 for A. Since this is an out-of-network claim, the cost-sharing ($2220) should count toward out-of-network OOPM. But does it also count toward in-network OOPM? In many plans, all cost-sharing for covered services (even out-of-network) accumulates toward the in-network OOPM? Actually, the Affordable Care Act requires that all cost-sharing for essential health benefits count toward the annual out-of-pocket maximum, regardless of network, but the out-of-network limit can be higher. But the plan document here provides an out-of-network OOPM of $12000, which is double the in-network. Usually, the out-of-network OOPM is a separate limit, and only out-of-network spending counts toward it. In-network spending counts toward in-network OOPM. But it's possible that the plan has a combined OOPM but with a higher cap for out-of-network. Given the document lists separate numbers, I'll assume they are separate accumulators. However, the prompt for this task asks for "ending_oopm_a", "ending_oopm_b", and "ending_family_oopm". It does not specify in-network vs out-of-network. It just says OOPM. Family OOPM is only listed for in-network ($12000). So perhaps the OOPM accumulator is a single value that encompasses both networks, but the cap differs. Or it could be that the OOPM tracking is just one number, but we need to apply the appropriate cap based on network. The prompt likely expects us to track a single OOPM balance for each member (and family) that accumulates all cost-sharing, and then for each claim we check if the member has hit the applicable OOP max. The document says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services". It doesn't say "in-network out-of-pocket maximum" for in-network services and "out-of-network out-of-pocket maximum" for out-of-network. It just says "the out-of-pocket maximum". The individual out-of-pocket maximum varies by network: $6000 in-network, $12000 out-of-network. So when you hit $6000 total cost-sharing (regardless of network), then in-network services are covered at 100%. When you hit $12000 total cost-sharing, out-of-network services are covered at 100%. This is typical: a single OOPM accumulator with two thresholds. So I'll treat OOPM as a single accumulator that accumulates all member cost-sharing (deductible, coinsurance, copays) for covered services. The ending_oopm_a will be the total cost-sharing A has paid so far. Then, for future claims, we'll check if that total has reached the threshold for the network of the claim. So after Claim 1, A's OOPM accumulator increases by $2220, from 900 to 3120. No OOPM cap hit yet for either network (since 3120 < 6000 and <12000). So Claim 1's responsibility is member 2220, plan 180.
Now Claim 2: B (spouse), in-network outpatient imaging, allowed 1300, billed 2405. In-network. B's current deductible accumulator = 0. In-network deductible threshold for B is $1500. So remaining deductible = 1500 - 0 = 1500. Allowed 1300, so all of it goes to deductible. Deductible applied = 1300. Member responsibility = 1300 (no coinsurance because deductible not met yet, and no copay listed for outpatient imaging; it's not a primary care, specialist, urgent, ER, or pharmacy, so it's subject to deductible and coinsurance). So member pays 1300. Plan pays 0. B's deductible accumulator becomes 1300. Family deductible accumulator was 900 from A, now add 1300, so family deductible = 2200. Family OOPM: B's cost-sharing 1300 counts toward family OOPM. Starting family OOPM = 900 (from A's previous). Add 1300 -> family OOPM becomes 2200. B's OOPM accumulator (single) becomes 1300. A's OOPM was 3120, so family OOPM sum of individual OOPMs? Actually family OOPM accumulator is typically the sum of all family members' cost-sharing. So family OOPM after claim 2 = 900+2220+1300? Wait, A's previous 900 OOPM, then A's claim 1 added 2220, so A's individual OOPM = 3120. B's claim 2 adds 1300, so B's individual OOPM = 1300. Family OOPM = aggregate of all family members' OOP spending: starting 900, after claim 1 it became 3120 (since A's increase 2220), after claim 2 it becomes 3120+1300 = 4420. Let's check: family OOPM starting was 900 (same as A's because only A had claims). After Claim 1, family OOPM should be 900+2220=3120. Yes. So after Claim 2, family OOPM = 3120+1300=4420. Good.
Claim 3: A, in-network follow-up procedure, allowed 1800, billed 3330. In-network. A's current deductible accumulator = 3000 (from claim 1). In-network threshold is 1500, already met. So no deductible applied. Member pays coinsurance: 20% of allowed = 360. Plan pays 80% = 1440. No copay. Member responsibility = 360. Check OOPM: A's current OOPM = 3120. In-network OOP max is $6000. After this claim, A's OOPM becomes 3120+360=3480, still under $6000. So member pays 360. Deductible applied = 0. Coinsurance amount = 360. So member_responsibility=360, plan_paid=1440. Update accumulators: A's deductible accumulator remains 3000 (no new deductible). A's OOPM = 3480. Family deductible: remains 3000 (since A already met family deductible? Family deductible is $3000. After claim 2, family deductible was 2200. A's deductible accumulator is 3000, but family deductible is aggregate of family deductible credits. However, embedded structure: "the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." Family deductible is $3000. The family deductible accumulator tracks total deductible payments across all family members. After claim 1, A added 2100, so family deductible = 900+2100=3000 (since starting 900, plus 2100 = 3000). That already meets family deductible of $3000. So after claim 1, family deductible = 3000, satisfied. Then claim 2 added 1300, but family deductible was already at 3000, so it doesn't go beyond? The family deductible accumulator might cap at the family limit? Typically, the family deductible is satisfied once total family member deductible contributions reach $3000. Any additional deductible payments after that don't increase the family deductible further; they just accumulate to individual balances. But the family deductible accumulator is often tracked as the lesser of actual family-wide deductible spending and the family limit. However, since it's embedded, once the family deductible is met, all family members' deductibles are considered met for the rest of the year. So after claim 1, family deductible was 3000, so met. So claim 2's deductible payment of 1300 would be after family deductible already met, so B's deductible should have been considered met? But wait, we adjudicated claim 2 as if B's individual deductible was not met, because we applied the full 1300 to deductible. But if family deductible was already met after claim 1, then B's claim 2 would not require deductible because the family deductible is satisfied, making all individual deductibles satisfied. The plan says: "Structure: EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." That means once total family credits reach $3000, the family deductible is satisfied, and that means all family members' deductibles are considered satisfied, regardless of individual progress. So when claim 2 occurs, the family deductible is already satisfied (after claim 1, family credits = 3000). So claim 2 should have no deductible applied; instead, B would pay coinsurance only, because the deductible is met for all. Did we misinterpret the order? Let's re-evaluate: Claim 1: A's out-of-network. A's deductible credits applied 2100, bringing family total deductible credits to 900+2100=3000. That satisfies the family deductible. So after claim 1, the family deductible is met. Then claim 2, which is in-network for B, should have the deductible considered already satisfied. Therefore, B would not need to pay any deductible; B would just pay coinsurance (20% of allowed, since in-network). That would change claim 2's cost-sharing. Let's recalc claim 2 under that rule. So I need to see if the family deductible being met means individual deductibles are all met. The embedded structure: individual can satisfy individually, or family aggregate satisfies all. The family deductible is $3000, individual $1500. Since after claim 1, total family credits = 3000, the family deductible is satisfied. So for any subsequent claim, the deductible is considered met for all members. So claim 2: B, in-network imaging, allowed 1300. Deductible already met, so member pays coinsurance 20% of 1300 = 260. No deductible applied. So member responsibility = 260, plan paid = 1040. Then accumulators: B's deductible accumulator would not increase (it remains 0? Actually, B's deductible credits might still accumulate even though family deductible met? The concept of "deductible satisfied" means no further deductible cost-sharing, but the accumulator for tracking individual progress might still be recorded, but for OOPM purposes, the amount paid as coinsurance counts. The question of whether B's individual deductible accumulator gets credited with the payment that was not required? Typically, if the family deductible is met, no further deductible is required, and those claims do not accumulate to the deductible because they are not applied to deductible. So B's deductible accumulator stays 0. Family deductible accumulator already capped at 3000. So after claim 2, family deductible remains 3000. B's OOPM: 260. Family OOPM: previous family OOPM after claim 1 was 3120 (A's OOPM 3120, B 0). Then claim 2 adds 260, so family OOPM = 3380. This is the correct adjudication order considering the embedded family deductible. I must re-adjudicate all claims sequentially, keeping in mind that after claim 1 family deductible is met, so all subsequent claims have no deductible regardless of individual accumulators. Also, out-of-network deductible threshold is $3000 individual, but family deductible met also satisfies that? The family deductible is $3000, which equals the out-of-json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
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{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
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},
{
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"got": 960,
"ok": true,
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},
{
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},
{
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{
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{
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},
{
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},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}33Claude Sonnet 5 · Anthropic18.9s · 2,117 out | 50.4s · 5,407 out | 15.2s · 1,666 out
json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "1500.00",
"ending_oopm_a": "3220.00",
"ending_deductible_b": "1300.00",
"ending_oopm_b": "1300.00",
"ending_family_deductible": "2800.00",
"ending_family_oopm": "4520.00"
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": "960.00",
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
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},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
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},
{
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"ok": false,
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},
{
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"got": "4520.00",
"ok": false,
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},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "1500.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "3220.00",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "1300.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "1300.00",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3000.00",
"ending_oopm_a": "4120.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3000.00",
"ending_family_oopm": "4380.00"
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": "960.00",
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4380.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3000.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4120.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "1500.00",
"ending_oopm_a": "3220.00",
"ending_deductible_b": "1300.00",
"ending_oopm_b": "1300.00",
"ending_family_deductible": "2800.00",
"ending_family_oopm": "4520.00"
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": "960.00",
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "2800.00",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4520.00",
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "1500.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "3220.00",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "1300.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "1300.00",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}33Claude Sonnet 4.6 · Anthropic22.2s · 1,552 out | 24.8s · 1,731 out | 21.8s · 1,465 out
I need to adjudicate claims in order, tracking accumulators carefully.
**Starting accumulators:**
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family: deductible 900.00, OOPM 900.00
**Key plan rules:**
- Individual deductible: 1500.00 (in-network threshold), 3000.00 (out-of-network threshold)
- Family deductible: 3000.00
- In/out-of-network credits accumulate to a SINGLE member deductible balance
- Individual OOPM: 6000.00 (in-network), 12000.00 (out-of-network)
- Family OOPM: 12000.00
- OON coinsurance: 40% member / 60% plan
- Copays do NOT credit deductible; copays DO credit OOPM
**Important:** The single deductible balance is measured against 1500 (in-network) or 3000 (out-of-network) depending on service type. So for OON services, A's deductible threshold is 3000.00.
---
**Claim 1 — A — OON specialist procedure — Allowed: 2400.00**
A's current deductible accumulator: 900.00. OON threshold: 3000.00. Remaining OON deductible: 3000 - 900 = 2100.00.
Deductible applied: min(2400.00, 2100.00) = 2400.00 (A's deductible accumulator goes to 3300.00... wait, but the allowed is 2400, so deductible applied = 2400.00).
After deductible: 0 remaining for coinsurance. Member pays 2400.00 as deductible.
A deductible accumulator: 900 + 2400 = 3300.00 (but OON individual threshold is 3000, so A's OON deductible is satisfied at 3000; the accumulator holds 3300 but deductible is met).
Actually the accumulator just tracks the running total. A's balance is now 3300.00. OON threshold is 3000, so deductible satisfied.
OOPM: A's OOPM accumulator: 900 + 2400 = 3300.00. OON individual OOPM is 12000.00. Family OOPM: 900 + 2400 = 3300.00.
After Claim 1: A deductible: 3300.00, A OOPM: 3300.00, B deductible: 0.00, B OOPM: 0.00, Family deductible: 3300.00 (≥3000, satisfied), Family OOPM: 3300.00.
---
**Claim 2 — B — IN-network outpatient imaging — Allowed: 1300.00**
Family deductible is satisfied (3300 ≥ 3000). So B pays no deductible. B goes straight to coinsurance: 20% member.
Member coinsurance: 1300 × 20% = 260.00. Plan pays 1040.00.
B OOPM: 0 + 260 = 260.00. Family OOPM: 3300 + 260 = 3560.00.
After Claim 2: A deductible: 3300.00, A OOPM: 3300.00, B deductible: 0.00 (accumulator stays 0, family deductible already met), B OOPM: 260.00, Family deductible: 3300.00, Family OOPM: 3560.00.
---
**Claim 3 — A — IN-network follow-up procedure — Allowed: 1800.00**
A's deductible accumulator: 3300. IN-network threshold: 1500. Already satisfied. Family deductible satisfied. No deductible applies.
Coinsurance (in-network): 20% member = 1800 × 20% = 360.00. Plan pays 1440.00.
A OOPM: 3300 + 360 = 3660.00. Family OOPM: 3560 + 360 = 3920.00.
After Claim 3: A deductible: 3300.00, A OOPM: 3660.00, B deductible: 0.00, B OOPM: 260.00, Family deductible: 3300.00, Family OOPM: 3920.00.
---
**Claim 4 — A — OON diagnostic study — Allowed: 1600.00**
A's deductible accumulator: 3300 ≥ 3000 (OON threshold). Deductible satisfied. No deductible applies.
OON coinsurance: 40% member = 1600 × 40% = 640.00. Plan pays 960.00.
A OOPM (OON individual limit 12000): 3660 + 640 = 4300.00 < 12000. Family OOPM: 3920 + 640 = 4560.00.
Claim 4 components: deductible_applied = 0.00, copay = 0.00, coinsurance = 640.00, member_responsibility = 640.00, plan_paid = 960.00.
json{
"member_responsibility": "640.00",
"plan_paid": "960.00",
"deductible_applied": "0.00",
"copay_amount": "0.00",
"coinsurance_amount": "640.00",
"ending_deductible_a": "3300.00",
"ending_oopm_a": "4300.00",
"ending_deductible_b": "0.00",
"ending_oopm_b": "260.00",
"ending_family_deductible": "3300.00",
"ending_family_oopm": "4560.00"
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": "960.00",
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": "640.00",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": "3300.00",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": "4560.00",
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": "3300.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": "4300.00",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": "260.00",
"ok": true,
"present": true
}
],
"fabricated": true,
"abstained": false
}I need to adjudicate each claim in order, tracking accumulators carefully.
**Starting accumulators:**
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family: deductible 900.00, OOPM 900.00
**Key plan rules:**
- Individual deductible: 1500.00 (in-network threshold); OON individual deductible: 3000.00
- "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
- Family deductible: 3000.00 (embedded)
- Individual OOPM in-network: 6000.00; OON: 12000.00
- Family OOPM: 12000.00
- Coinsurance OON: 40% member / 60% plan
- Coinsurance in-network: 20% member / 80% plan
- Copays don't credit deductible; copays credit OOPM
**Deductible interpretation:** The single balance is measured against 1500 (in-network threshold) or 3000 (OON threshold). A's deductible balance is 900. For an OON claim, the threshold is 3000. The member is responsible for deductible until their balance reaches 3000 (OON) or 1500 (in-network).
---
**Claim 1 — A, OON specialist procedure, allowed 2400.00**
A's deductible balance: 900.00. OON threshold: 3000.00. Remaining deductible needed: 3000 - 900 = 2100.00.
Allowed = 2400.00. Deductible applied = min(2100.00, 2400.00) = 2100.00.
Remaining after deductible: 2400 - 2100 = 300.00 → coinsurance at 40% member.
Coinsurance member: 300 × 0.40 = 120.00.
Member responsibility: 2100 + 120 = 2220.00.
Plan paid: 2400 - 2220 = 180.00.
OOPM check: A's OOPM is OON → 12000.00. A's OOPM accumulator: 900 + 2220 = 3120.00. Under 12000, OK.
After Claim 1:
- A: deductible balance = 900 + 2100 = 3000.00 (OON deductible satisfied; also satisfies in-network since 3000 > 1500), OOPM = 3120.00
- Family deductible: 900 + 2100 = 3000.00 → **family deductible satisfied**
- Family OOPM: 900 + 2220 = 3120.00
---
**Claim 2 — B, in-network outpatient imaging, allowed 1300.00**
Family deductible is satisfied. B's individual deductible balance: 0.00. In-network threshold 1500 — B hasn't met it. But family deductible is satisfied (embedded: family met), so does B get coinsurance?
Under embedded structure: once family deductible is met, all members get coinsurance. B's individual deductible not met individually, but family deductible satisfied → plan pays coinsurance for B.
Coinsurance: 20% member. Member: 1300 × 0.20 = 260.00. Plan: 1040.00.
B's deductible credit: the 1300 applied goes to deductible? Actually since family deductible is already satisfied, the deductible_applied = 0 for B here. Member pays coinsurance only.
OOPM: B OOPM (in-network) = 6000. B accumulator: 0 + 260 = 260.00.
Family OOPM: 3120 + 260 = 3380.00.
After Claim 2:
- B: deductible 0.00 (no additional deductible applied, but B's balance stays at 0... actually the 1300 doesn't count toward B's deductible since family already satisfied), OOPM = 260.00
- Family deductible: 3000.00, Family OOPM: 3380.00
---
**Claim 3 — A, in-network follow-up procedure, allowed 1800.00**
A's deductible balance 3000 ≥ 1500 (in-network threshold) → satisfied. Coinsurance: 20% member.
Member: 1800 × 0.20 = 360.00. Plan: 1440.00.
A OOPM: 3120 + 360 = 3480.00 < 6000. OK.
Family OOPM: 3380 + 360 = 3740.00.
After Claim 3:
- A: deductible 3000.00, OOPM = 3480.00
- Family: deductible 3000.00, OOPM = 3740.00
---
**Claim 4 — A, OON diagnostic study, allowed 1600.00**
A's deductible balance: 3000.00. OON threshold: 3000.00 → satisfied. Coinsurance: 40% member.
Member coinsurance: 1600 × 0.40 = 640.00. Plan: 960.00.
A OOPM (OON individual): 12000.00. A accumulator: 3480 + 640 = 4120.00 < 12000. OK.
Family OOPM: 3740 + 640 = 4380.00 < 12000. OK.
Deductible applied: 0.00. Copay: 0.00. Coinsurance: 640.00.
**Ending accumulators:**
- A: deductible 3000.00, OOPM 4120.00
- B: deductible 0.00, OOPM 260.00
- Family: deductible 3000.00, OOPM 4380.00
json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 0.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}I need to adjudicate all four claims in sequence, tracking accumulators carefully.
**Starting accumulators:**
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family: deductible 900.00, OOPM 900.00
**Key plan rules:**
- Individual deductible: 1500.00 (in-network threshold), but OON deductible threshold is 3000.00
- Family deductible: 3000.00
- In/OON deductible credits accumulate to a SINGLE member deductible balance
- OOPM individual in-network: 6000.00; OON individual: 12000.00; Family: 12000.00
- After deductible: in-network 20% member / 80% plan; OON 40% member / 60% plan
- Copays don't credit deductible; copays always credit OOPM
**Claim 1 — A — OON specialist procedure — Allowed: 2400.00**
A's current deductible accumulator: 900.00. OON deductible threshold for individual: 3000.00. Family deductible threshold: 3000.00, family accumulator: 900.00.
A needs 3000.00 - 900.00 = 2100.00 more to satisfy OON individual deductible.
Family needs 3000.00 - 900.00 = 2100.00 more.
Allowed = 2400.00. Apply to deductible first: 2100.00 goes to deductible (limited by both individual OON remaining = 2100.00 and family remaining = 2100.00; both are equal, so 2100.00).
Remaining after deductible: 2400.00 - 2100.00 = 300.00
OON coinsurance: 40% member × 300.00 = 120.00
Member responsibility: 2100.00 + 120.00 = 2220.00
Plan paid: 2400.00 - 2220.00 = 180.00
A accumulators after Claim 1:
- Deductible: 900.00 + 2100.00 = 3000.00 (individual OON threshold met; also in-network threshold 1500.00 met since 3000.00 > 1500.00)
- OOPM: 900.00 + 2220.00 = 3120.00
Family: deductible 900.00 + 2100.00 = 3000.00 (family deductible SATISFIED), OOPM 900.00 + 2220.00 = 3120.00
**Claim 2 — B — In-network outpatient imaging — Allowed: 1300.00**
Family deductible is now satisfied (3000.00). B's individual deductible: 0.00, but family is satisfied, so B owes no deductible. B's individual in-network deductible: 0.00 < 1500.00, but the family deductible being satisfied means...
Under embedded structure: individual satisfies on their own OR family total satisfies. Family deductible is satisfied. So B gets coinsurance treatment immediately.
In-network coinsurance: 20% member × 1300.00 = 260.00
Plan paid: 1300.00 - 260.00 = 1040.00
B accumulators after Claim 2:
- Deductible: 0.00 + 1300.00 = 1300.00 (family already satisfied; B's individual balance is 1300.00 but moot)
- OOPM: 0.00 + 260.00 = 260.00
Family: deductible stays 3000.00 (satisfied), OOPM: 3120.00 + 260.00 = 3380.00
**Claim 3 — A — In-network follow-up procedure — Allowed: 1800.00**
A's deductible accumulator: 3000.00 — individual in-network threshold 1500.00 is met. Deductible satisfied.
In-network coinsurance: 20% × 1800.00 = 360.00. Plan: 1440.00.
A OOPM: 3120.00 + 360.00 = 3480.00. Family OOPM: 3380.00 + 360.00 = 3740.00
**Claim 4 — A — OON diagnostic study — Allowed: 1600.00**
A's deductible: 3000.00 (OON threshold 3000.00 met). Deductible satisfied.
OON coinsurance: 40% × 1600.00 = 640.00. Plan: 960.00.
A OOPM: 3480.00 + 640.00 = 4120.00 (< 12000.00 OON individual OOPM).
Family OOPM: 3740.00 + 640.00 = 4380.00.
json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 1300.00,
"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 4380,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 1300,
"ok": false,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 260,
"ok": true,
"present": true
}
],
"fabricated": true,
"abstained": false
}33Claude Haiku 4.5 · Anthropic109.9s · 12,431 out | 124.3s · 13,616 out | 152.7s · 15,808 out
Reasoning · 12,252 tokens
Let me work through this step by step.
PLAN DETAILS:
- Individual deductible (in-network): 1500.00
- Family deductible (in-network): 3000.00
- Individual deductible (out-of-network): 3000.00
- Structure: EMBEDDED - in-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance
- Individual OOPM (in-network): 6000.00
- Family OOPM (in-network): 12000.00
- Individual OOPM (out-of-network): 12000.00
- Coinsurance (in-network): 20% member / 80% plan
- Coinsurance (out-of-network): 40% member / 60% plan
- Copays do NOT credit the deductible but DO credit OOPM
STARTING ACCUMULATORS:
- A deductible: 900.00
- A OOPM: 900.00
- B deductible: 0.00
- B OOPM: 0.00
- Family deductible: 900.00
- Family OOPM: 900.00
Now let me process each claim:
**CLAIM 1 — 2026-05-05 — A (subscriber)**
Service: Out-of-network specialist procedure
Network: Out-of-network
Billed: 4440.00
Allowed: 2400.00
A is out-of-network, so:
- Out-of-network deductible: 3000.00
- Out-of-network coinsurance: 40% member / 60% plan
- Out-of-network OOPM: 12000.00
A's deductible accumulator sits at 900.00, leaving 2100.00 remaining against the 3000.00 out-of-network individual deductible. Family deductible is also at 900.00, with 2100.00 remaining toward the 3000.00 family threshold.
Since the plan uses a single embedded deductible balance per member across networks, A's applicable deductible here is 3000.00 regardless of which network the service falls under.
out-of-network deductible threshold. So there's one shared accumulator, but it's measured against different thresholds depending on network status.
Starting deductible accumulator for A: 900.00.
Claim 1 (out-of-network):
- Remaining deductible: 3000.00 - 900.00 = 2100.00
- Allowed amount: 2400.00
- Deductible applied: min(2400.00, 2100.00)
- Remaining after deductible: 2400.00 - 2100.00 = 300.00
- Coinsurance: 300.00 × 0.40 = 120.00
- Member owes: 2100.00 + 120.00 = 2220.00
- Plan pays: 180.00 (checks out: 2220 + 180 = 2400)
A's deductible accumulator: 900 + 2100 = 3000.00
A's OOPM accumulator: 900 + 2220 = 3120.00
Family deductible accumulator also reaches 3000.00
Claim 2 — B, in-network imaging, billed 2405.00, allowed 1300.00. B's individual deductible is 1500, family deductible is 3000. Before this claim, B's deductible accumulator is 0, so remaining individual deductible is 1500.00. But family deductible accumulator is already at 3000 (the full family deductible), meaning remaining family deductible is 0.
Under embedded rules, once the family deductible is fully met, all family members' deductibles are considered satisfied. But B individually hasn't met the 1500 individual deductible yet. Since embedded plans satisfy either individually or via family, and family is already met, B's deductible obligation is waived here.
So allowed 1300.00 goes straight to coinsurance: member 20% = 260.00, plan pays 80% = 1040.00. Apply this to B's OOPM.
B's deductible accumulator stays at 0.00, OOPM accumulator becomes 260.00.
Family deductible remains 3000.00, family OOPM becomes 3120.00 + 260.00 = 3380.00.
**CLAIM 3 — 2026-06-14 — A (subscriber)**
In-network follow-up, billed 3330.00, allowed 1800.00.
A's in-network deductible is 1500.00, coinsurance 20/80, OOPM 6000.00. A's deductible accumulator sits at 3000.00, well past the 1500 threshold — deductible already satisfied.
Re-reading the deductible structure: single accumulator shared across in/out-of-network credits, but the threshold checked differs by service type (1500 in-network, 3000 out-of-network). Since A's 3000.00 balance clears the 1500 in-network threshold, A's deductible is fully met for this claim.
Family deductible was already satisfied after Claim 1.
Claim 3 calculation: deductible satisfied, allowed amount 1800.00, 20% coinsurance = 360.00 member responsibility, plan pays 1440.00.
A's deductible stays at 3000.00, OOPM rises to 3480.00. Family deductible stays at 3000.00, family OOPM rises to 4780.00.
Moving to Claim 4.
026-07-08 — A (subscriber)**
Out-of-network diagnostic study, billed 2960.00, allowed 1600.00. Out-of-network terms apply: deductible threshold 3000.00, coinsurance 40%/60%, OOPM 12000.00.
A's deductible accumulator is already at 3000.00, fully met. So for Claim 4, coinsurance applies at 40%: 1600.00 × 0.40 = 640.00 member responsibility, plan pays the remainder.
Plan paid: 1600.00 - 640.00 = 960.00
A's deductible accumulator stays at 3000.00, OOPM rises to 3480.00 + 640.00 = 4120.00
Family deductible stays at 3000.00, family OOPM rises to 4780.00 + 640.00 = 5420.00
Compiling Claim 4:
- member_responsibility: 640.00
- plan_paid: 960.00
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 640.00
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 1300.00
B's OOPM stays at 1300.00 too, since no B claims occurred here.
Family deductible: 3000.00, family OOPM: 5420.00
Now I need to verify the OOPM structure — does the plan track separate in-network vs out-of-network maximums, or one combined figure per member? The document lists individual OOPM (in-network) at 6000.00, individual (out-of-network) at 12000.00, and family (in-network) at 12000.00, with no out-of-network family figure shown. This suggests network-specific tracking rather than a single unified OOPM per person.
individual) ............ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So the deductible structure uses one shared accumulator: 1500.00 threshold for in-network, 3000.00 threshold for out-of-network individual, with 3000.00 family in-network. Same shared-balance logic likely applies to the OOPM section, which I need to check next.
For OOPM the document lists individual in-network at 6000.00, family in-network at 12000.00, and individual out-of-network at 12000.00 - no family out-of-network figure and no explicit shared-accumulator statement like the deductible had. I'm inclined to assume a single OOPM accumulator per member, where the applicable ceiling depends on whether services are in- or out-of-network (6000 vs 12000 individual), with 12000 serving as the family cap.
allowed amount for covered services for the rest of the plan year." The family OOPM listing only shows 12000 for in-network, with no separate out-of-network family figure given—this leaves the structure ambiguous.
One reading: individual has distinct in-network (6000) and out-of-network (12000) maximums, while family shares a single 12000 cap regardless of network. Another possibility is that family OOPM only governs in-network accumulation, with no defined out-of-network family limit at all.
I need to check how embedded deductible/OOPM structures typically interact with family caps: "EMBEDDED — an individual satisfies the individual deductible on their own; the family deductible..."
This clarifies the deductible mechanic but doesn't explicitly address OOPM family/individual interaction. Standard embedded OOPM logic usually has each member track their own accumulator, with a separate family accumulator tracked in parallel—once either threshold hits, that member (or the whole family) gets 100% coverage. Given individual in-network is 6000, individual out-of-network is 12000, and family is 12000, the family OOPM likely isn't simply the sum of individuals but a separate cap that members' costs accumulate toward jointly.
starting accumulators, but only one "out-of-pocket" field per member—no in-network/out-of-network split. So I'll treat it as a single OOPM per member that just accumulates regardless of network, though the limit itself might differ (6000 in-network vs 12000 out-of-network). Maybe simplest is to use the max, 12000, as the effective individual cap. Family OOPM stays a single 12000 accumulator covering everyone.
I need to check what the accumulator table actually says under "FAMILY ACCUMULATORS as of the moment before Claim 1" to confirm this structure.
- Family out-of-network: 24000.00
This confirms separate limits by network status, but only one accumulator tracked per person—likely meaning all costs (in and out-of-network) feed into the same running total, with the applicable limit depending on which type of service triggers the cap.
-network services, cost share counts toward the 12000 out-of-network OOPM. So I'll treat these as separate accumulators, but the problem only gives one per member.
Simplest reading: single OOPM accumulator per member, with threshold depending on network type used — 6000 if in-network only, 12000 if out-of-network involved. Family OOPM threshold is 12000 across all services.
Since A used out-of-network services, A's OOPM limit is 12000. Though there's another possible interpretation of how the out-of-network OOPM interacts with the accumulator worth considering.
- for family it's 12000.
A used out-of-network in Claim 1, so A's threshold is 12000. B only used in-network so far, so B's threshold is 6000.
The task asks for "ending_oopm_a" and "ending_oopm_b" - these are accumulator values, not limits. Tracking accumulators: after Claim 1, A's OOPM = 900.00 + 2220.00 = 3120.00.
After Claim 2: B's OOPM = 0.00 + 1300.00 = 1300.00.
After Claim 3: A's OOPM = 3120.00 + 360.00 = 3480.00.
After Claim 4: A's OOPM = 3480.00 + 640.00 = 4120.00.
I should double-check the OOPM structure isn't double-counting in-network/out-of-network. The plan states deductible credits from both in-network and out-of-network accumulate to a single member balance - same logic likely applies to OOPM.
But OOPM lacks that explicit unification statement, just listing separate figures: 6000 in-network, 12000 out-of-network. This could mean separate limits stacking (6000 + 12000), or it could mean different scenarios - 6000 cap if only in-network is used, 12000 cap if any out-of-network is used, applying across all costs.
The second interpretation seems more sensible given no explicit "separate accumulator" language exists. So I'll treat this as a single OOPM accumulator per member, with the threshold determined by whether out-of-network services were used.
Since A used out-of-network care, A's cap is 12000; since B stayed in-network, B's cap is 6000.
Finalizing Claim 4: member_responsibility 640.00, plan_paid 960.00, deductible_applied 0.00, copay 0.00, coinsurance 640.00.
Ending accumulators: deductible_a 3000.00, oopm_a 4120.00, deductible_b 1300.00, oopm_b 1300.00, family_deductible 3000.00, family_oopm 5420.00.
Now verifying each claim's math starting from Claim 1.
For Claim 1 (out-of-network specialist, A), allowed is 2400.00 with A's deductible sitting at 900.00 against a 3000.00 threshold, leaving 2100.00 remaining. Apply the full 2100.00 to deductible, leaving 300.00 allowed subject to 40% coinsurance = 120.00. Member responsibility totals 2220.00, plan pays 180.00, pushing A's deductible after to 3000.00.
.00 + 2100.00 = 3000.00
- A's OOPM after: 900.00 + 2220.00 = 3120.00
- Family deductible after: 900.00 + 2100.00 = 3000.00
- Family OOPM after: 900.00 + 2220.00 = 3120.00
**CLAIM 2 — 2026-05-21 — B (spouse)**
- Service: In-network outpatient imaging
- Network: In-network
- Allowed: 1300.00
- B's deductible before: 0.00
- B's individual deductible threshold: 1500.00
- Family deductible before: 3000.00 (already satisfied)
- B needs to satisfy their individual deductible
- Remaining individual deductible for B: 1500.00 - 0.00 = 1500.00
- Apply deductible:
min(1300.00, 1500.00) = 1300.00, entire allowed goes to deductible
- Remaining allowed after deductible: 0.00, so no coinsurance applies
- Member responsibility: 1300.00, plan pays 0.00
- B's deductible/OOPM after: 1300.00 each
- Family deductible stays at 3000.00, family OOPM climbs to 4420.00
**CLAIM 3 — 2026-06-14 — A (subscriber)**
- In-network follow-up procedure, checking allowed amount next
Allowed: 1800.00, and A's deductible (3000.00) already exceeds the 1500.00 threshold, so it's fully satisfied. Full 1800.00 subject to 20% coinsurance = 360.00 member responsibility, plan pays 1440.00. A's OOPM rises to 3480.00, family OOPM to 4780.00, deductibles unchanged.
**CLAIM 4 — 2026-07-08 — A (subscriber)**
Out-of-network diagnostic study, allowed 1600.00. A's deductible (3000.00) meets the out-of-network threshold (3000.00), so fully satisfied. Entire 1600.00 subject to 40% coinsurance = 640.00 member responsibility, plan pays 960.00. A's OOPM becomes 4120.00, family OOPM becomes 5420.00, deductibles remain at 3000.00.
Final answer for Claim 4: member_responsibility = 640.00
For plan_paid, deductible_applied, copay_amount, and coinsurance_amount, plan_paid = 960.00, deductible_applied = 0.00, copay_amount = 0.00, coinsurance_amount = 640.00.
Ending accumulators: A's deductible stays at 3000.00, A's OOPM rises to 4120.00. B's figures remain unchanged at 1300.00 deductible and 1300.00 OOPM. Family deductible holds at 3000.00, family OOPM increases to 5420.00.
I need to double-check the required output format — the task calls for reporting Claim 4 components plus ending accumulators for both members and the family, with keys including member_responsibility, plan_paid, deductible_applied, and copay...
I confirm all 11 required keys are present: member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount, ending_deductible_a, ending_oopm_a, ending_deductible_b, ending_oopm_b, ending_family_deductible, ending_family_oopm. Now formatting the JSON response with member_responsibility at 640.00 and plan_paid at 960.00, deductible_applied 0.00, copay_amount 0.00.
Double-checking the numbers before finalizing - starting with A's deductible at 900.00 and OOPM at 900.00, B's deductible and OOPM both at 0.00, family totals matching A's individual amounts at 900.00 each. Now working through Claim 1 for A, out-of-network with an allowed amount of 2400.
With A's OON deductible limit at 3000, the remaining deductible is 3000 - 900 = 2100. Applying this to the claim: min(2400, 2100) = 2100 goes to deductible, leaving 300 of allowed amount subject to 40% coinsurance = 120. Total member responsibility comes to 2100 + 120 = 2220, meaning the plan pays 180.
After this claim: A's deductible hits 3000 (fully met), A's OOPM reaches 3120, family deductible also hits 3000, and family OOPM reaches 3120.
Claim 2: B, in-network, allowed 1300. Since B's individual deductible (limit 1500) hasn't been touched yet, even though the family deductible is satisfied, B still needs to meet their own individual amount. Applying min(1300, 1500) = 1300 fully to deductible leaves nothing for coinsurance. Member pays the full 1300, plan pays 0.
Post-claim: B's deductible and OOPM both sit at 1300, family deductible stays at 3000, family OOPM climbs to 4420.
Claim 3: A, in-network, allowed 1800. A's deductible (INN limit 1500) is already exceeded by the 3000 accumulated, so no deductible applies here - straight to 20% coinsurance.
deductible tracking is consistent across both in-network and out-of-network accumulators — family deductible should mirror individual deductible progression regardless of network type. The plan
says structure is EMBEDDED: individual satisfies their own deductible OR family satisfies once total credits hit family amount, whichever comes first. Deductible credits combine into a single balance per member.
So family deductible of 3000 gets satisfied by combined network credits. Claim 1's A contributes 2100 out-of-network, pushing family from 900 to 3000 — satisfied. Claim 2's B uses 1300 in-network, but family deductible is already met by that point.
individual has their own threshold, family has its own threshold, and whichever hits first satisfies that layer.
For Claim 1: A's out-of-network threshold is 3000, and A's accumulator moves from 900 to 3000 — fully satisfying A's individual deductible. Meanwhile the family accumulator also needs tracking to see if it crosses 3000 first.
For Claim 2: B's in-network threshold is 1500, but B's accumulator only reaches 1300 — not yet met. If family is already satisfied from Claim 1, B's costs shift to coinsurance regardless.
For Claim 3: A's in-network threshold is 1500, already exceeded since A's accumulator is at 3000. So this claim processes under coinsurance since both individual and family layers are satisfied.
For Claim 4: A's out-of-network threshold is 3000, matching A's current accumulator. Already satisfied here too.
This confirms embedded deductible logic: each person accumulates independently toward their own threshold, while all contributions also feed into a shared family total. A person can hit their individual deductible either directly or by the family deductible being met first, whichever comes first satisfies their coverage.
For B in Claim 2 - the family deductible reached its threshold, but B's personal accumulator hasn't hit their individual threshold. Under embedded rules, deductible satisfaction happens the moment EITHER the individual threshold OR the family threshold is met - whichever occurs first. So once family deductible is satisfied, that should trigger coverage for all family members, even if their individual accumulator hasn't separately reached the individual threshold.
I should verify the out-of-pocket maximum details too. The plan pays 100% once OOPM is reached, and copays always credit toward OOPM - but none of these claims involve copays, so that's not a factor here.
Checking accumulators against limits: A is at 4120/12000, B is at 1300/6000, and family is at 5420/12000 - nobody's hit their max yet.
Everything checks out. Final answer:
```json
{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 1300.00,
"ending_oopm_b": 1300.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 5420.00
}
```
json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 1300.00,
"ending_oopm_b": 1300.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 5420.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 5420,
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 1300,
"ok": false,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 1300,
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}Reasoning · 13,436 tokens
Let me carefully work through this step by step.
**PLAN DETAILS:**
- Individual in-network deductible: 1500.00
- Family in-network deductible: 3000.00
- Individual out-of-network deductible: 3000.00
- Structure: EMBEDDED - in-network and out-of-network credits accumulate to a SINGLE member deductible balance. The out-of-network amount (3000.00) is the threshold when the service is out-of-network.
- Individual in-network OOPM: 6000.00
- Family in-network OOPM: 12000.00
- Individual out-of-network OOPM: 12000.00
- Coinsurance after deductible, out-of-network: 40% member / 60% plan
Wait, let me re-read the deductible section more carefully:
"In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So for each member, deductible credits from both in-network and out-of-network services accumulate to a single balance. For out-of-network services, this balance is measured against the out-of-network individual deductible threshold (3000.00). For in-network services, the balance is measured against the in-network individual deductible (1500.00).
Actually, let me re-read this more carefully. The plan says:
- Individual (in-network): 1500.00
- Family (in-network): 3000.00
- Structure: EMBEDDED
- Out-of-network (individual): 3000.00
- "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
There's one deductible balance per member combining both in-network and out-of-network credits, but the threshold it's compared against depends on which type of service is being measured - 1500.00 for in-network, 3000.00 for out-of-network.
The EMBEDDED structure clarifies things further: "an individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." So each individual has their own deductible (1500.00 in-network), while the family shares a pooled deductible (3000.00 in-network) that's satisfied whichever way credits accumulate first.
For deductible tracking, credits from both in-network and out-of-network services accumulate to a single member balance, but the threshold differs depending on service type - 1500.00 for in-network, 3000.00 for out-of-network. Satisfying one type doesn't automatically satisfy the other separately.
So if a member has 1500.00 in credits from mixed services, in-network claims would be treated as deductible-met, but out-of-network claims would still need to reach 3000.00 total before that deductible is satisfied. The balance is shared, but the threshold checked depends on which network type the service falls under.
Then there's the embedded family layer to factor in — individual deductibles of 1500.00 in-network per person, plus a family-level
With embedded family, individual thresholds stay at 1500.00 in-network, and the family threshold is 3000.00 in-network. Balances get tracked separately per individual and for the family, but credits toward both come from the same pool of payments — whichever hits its threshold first triggers coinsurance. Out-of-network likely mirrors this pattern but at the higher 3000.00 individual threshold.
Checking the starting accumulators, A already has 900.00 applied to both deductible and OOPM. Time to trace through the claims starting with Claim 1 — a 2026-05-05 out-of-network service for subscriber A.
The specialist procedure bills 4440.00, allowed 2400.00, out-of-network, 40/60 coinsurance split.
Since the out-of-network deductible threshold is 3000.00 and A has 900.00 already applied, 2100.00 more is needed. The 2400.00 allowed amount covers this: 2100.00 satisfies the remaining deductible, leaving 300.00 of the allowed amount for coinsurance calculations.
Member owes 40% of the 300.00 remainder (120.00), plus the 2100.00 deductible = 2220.00 total. Plan covers 60% of 300.00 = 180.00. Checks out: 2220.00 + 180.00 = 2400.00.
A's deductible reaches 3000.00 (satisfied), OOPM reaches 3120.00. Since this is A's individual deductible/OOPM, family deductible also hits 3000.00 (satisfied), family OOPM stays at 900.00 since only A's costs count so far.
Now I need to double-check the out-of-network deductible threshold — the plan states in-network and out-of-network credits accumulate to a single member deductible balance, but the threshold changes depending on whether the service is in-network (1500.00) or out-of-network (3000.00). This seems to imply there's effectively a separate out-of-network individual deductible layered on top, with shared credit accumulation.
With 900.00 already applied to the balance: in-network needs 1500.00 - 900.00 = 600.00 more, out-of-network needs 3000.00 - 900.00 = 2100.00 more. That's consistent with the out-of-network deductible being higher.
For the family structure, being EMBEDDED means individual in-network is 1500.00, family in-network is 3000.00, and each can be satisfied independently. There's no explicit out-of-network family deductible specified—likely only an individual out-of-network deductible of 3000.00 applies, with no separate family threshold for out-of-network.
So claim processing logic: check if in-network and balance is under 1500.00 to apply deductible, then check the family threshold similarly.
Re-reading the embedded definition, "total family credits" reaching the family amount suggests it's the sum across all family members' deductible payments, not any single member's balance—so I need to track cumulative family credits separately from individual credits.
The starting accumulators show A at 900.00, B at 0.00, and family total at 900.00—individual and family are tracked as separate running totals. For each in-network claim, the deductible applied should be the lesser of the member's remaining individual deductible and the family's remaining deductible, satisfying whichever threshold is hit first. Now I need to work out how out-of-network claims factor into this.
A's out-of-network individual threshold is 3000.00, with no separate family deductible mentioned for out-of-network. This raises a question: does A's existing 900.00 from in-network apply toward this 3000.00? The note clarifies that in-network and out-of-network credits accumulate to a single member balance—so yes, A starts at 900.00 toward the 3000.00 out-of-network threshold. Still need to figure out how the family deductible factors in here.
For out-of-network, the individual threshold is 3000.00, but no family threshold is stated—so it's unclear if a family component even applies there.
The "whichever comes first" language clarifies the embedded logic: an individual satisfies their deductible either by hitting their own threshold, or by the family collectively hitting the family threshold—whichever happens sooner. So for in-network, someone's deductible is met at either 1500.00 individually or 3000.00 family-wide.
Since the deductible balance is shared across in and out-of-network categories, this raises a question: if A already applied 1500.00 toward in-network (satisfying that deductible), does A still need to independently reach 3000.00 for out-of-network? I believe yes—the categories are tracked separately even though the dollar amounts contribute to a shared running total.
Reconsidering the phrase "single member deductible balance": each member has one accumulator, but the threshold checked against depends on whether the service is in-network or out-of-network. So the same dollars count toward both, but you need to hit the higher out-of-network threshold before that category is considered satisfied.
Concretely: if 1500.00 has accumulated from in-network services, in-network is satisfied (1500>=1500) but out-of-network isn't (1500<3000), so out-of-network claims keep applying deductible until the balance hits 3000.00.
Restarting with this framework:
**Starting state:**
- A: deductible 900.00, OOPM 900.00
- B: deductible 0.00, OOPM 0.00
- Family: deductible 900.00, OOPM 900.00
**CLAIM 1 — A, Out-of-network specialist procedure**
- Allowed: 2400.00
- A's remaining out-of-network deductible: 3000.00 - 900.00 = 2100.00
- Deductible applied: min(2400.00, 2100.00) = 2100.00
Remaining allowed: 300.00, coinsurance 40/60:
- Member: 120.00, Plan: 180.00
Total member cost: 2100.00 + 120.00 = 2220.00
A's ending deductible: 3000.00
Now I need to figure out whether out-of-network claims count toward the family deductible.
Checking the plan design: family deductible only applies in-network; there's no family deductible for out-of-network. So the family deductible stays at 900.00 (unchanged by this out-of-network claim), while A's individual deductible hits 3000.00 (satisfied).
A's OOPM: 900.00 + 2220.00 = 3120.00
Family OOPM: 900.00 + 2220.00 = 3120.00
**CLAIM
amount: 1300.00, remaining individual: 1500.00, remaining family: 2100.00 — the min is 1300.00, so the entire allowed amount goes to deductible with no coinsurance applied.
Member owes 1300.00, plan pays 0.00.
Updated balances: B's deductible 0.00→1300.00, family deductible 900.00→2200.00, B's OOPM 0.00→1300.00, family OOPM →3120.00.
**Claim 3 (A, in-network follow-up)**
Allowed 1800.00. A's in-network deductible threshold is 1500.00, and A's current balance sits at 3000.00 — already past that threshold from out-of-network spending, so A's individual deductible is satisfied for in-network purposes.
Now checking the family side: family deductible balance is 2200.00 against a 3000.00 target, leaving 800.00 remaining. Need to work out how this interacts with A's already-satisfied individual threshold.
For embedded plans, once a member hits their individual deductible OR the family hits its total, that member is done — whichever occurs first. Since A's individual deductible is met, A's applied credits stop counting toward the deductible even if the family total hasn't been reached yet. This claim's allowed amount should go straight to coinsurance rather than deductible.
Now checking the family total against Claim 3: 2200.00 applied so far, family needs 800.00 more to hit 3000.00.
For A specifically, deductible was satisfied out-of-network already. For B, only 1300.00 has been applied against the 1500.00 individual threshold — not yet met individually, and family total hasn't reached 3000.00 either.
On Claim 3, A's individual deductible is already met, so no further deductible applies to A even though family deductible has 800.00 left. I think once an individual satisfies their own threshold, they stop contributing to the family accumulator.
So Claim 3 goes straight to coinsurance: 1800.00 allowed amount splits 20/80 — member owes 360.00, plan covers 1440.00.
A's OOPM after Claim 3: 3480.00. Family OOPM: 4780.00.
**CLAIM 4 — A, Out-of-network diagnostic study**
Allowed 1600.00. A's out-of-network deductible (3000.00) is already satisfied, so the whole amount goes to coinsurance at 40/60 — member pays 640.00, plan pays 960.00.
A's OOPM: 3480.00 + 640.00 = 4120.00
Family OOPM: 4780.00 + 640.00 = 5420.00
Let me double-check the family deductible tracking from the start — 900.00 initially applied, Claim 1's out-of-network amount didn't touch family deductible, so it stayed at 900.00 through Claim 2.
After Claim 2 (B, in-network): 1300.00 adds to family deductible, bringing it to 2200.00.
Claims 3 and 4 don't add anything further — Claim 3 because A's deductible is already met, Claim 4 because it's out-of-network. So the family deductible ends at 2200.00.
Final numbers for Claim 4: member_responsibility 640.00, plan_paid 960.00.
deductible_applied: 0.00
copay_amount: 0.00
coinsurance_amount: 640.00
Ending accumulators:
- ending_deductible_a: 3000.00
- ending_oopm_a: 4120.00
- ending_deductible_b: 1300.00
- ending_oopm_b: 1300.00
- ending_family_deductible: 2200.00
- ending_family_oopm: 5420.00
Double-checking claim 4: allowed 1600.00, 40% coinsurance gives 640.00 member responsibility, 960.00 plan paid, summing to 1600.00.
Now reconsidering out-of-network deductible structure. The plan states in-network and out-of-network credits accumulate to a single member deductible balance, but the threshold measured against changes depending on service type. Family deductible only has an in-network figure (3000.00) - there's no separate family out-of-network deductible specified. So for in-network services, individual and family deductibles both apply, while for out-of-network...
only the individual deductible applies, no family component involved.
For Claim 1 (out-of-network, A): only A's individual out-of-network threshold (3000.00) matters, family deductible untouched.
For Claim 2 (in-network, B): B's individual threshold (1500.00) and the family threshold (3000.00) both apply.
This confirms my earlier analysis. Moving to Claim 3 to verify the totals.
After Claim 2, accumulators stand at: A's deductible 3000.00, B's deductible 1300.00, family deductible 2200.00.
For Claim 3 (in-network, A): A's individual threshold is 1500.00, and A's balance (3000.00) already exceeds it, so A's deductible is satisfied. But the family threshold (3000.00) isn't met yet since family balance is only 2200.00.
The key question is whether family deductible still applies once A's individual deductible is satisfied — with embedded plans, I believe no, since satisfaction can happen either way.
Once satisfied, that member stops contributing to deductible even if the family total hasn't hit the family threshold. So for Claim 3, the full 1800.00 allowed amount goes to coinsurance: 360.00 member, 1440.00 plan. No deductible applied, family accumulator stays at 2200.00.
Let me double check by considering how embedded deductibles actually function more carefully.
this logic, after Claim 2, A's accumulated deductible is 3000.00, but that's measured against different thresholds depending on network status.
Wait, that doesn't add up against the out-of-network threshold. Let me re-read the plan.
"Out-of-network (individual) ................ 3000.00
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is the threshold that balance is measured against when the service is out-of-network."
So there's one shared balance but two thresholds: 1500.00 gates in-network services, 3000.00 gates out-of-network services.
Once the balance hits 1500.00, in-network claims stop applying deductible—but out-of-network claims keep applying deductible until the balance reaches 3000.00. So a member at 2000.00 would have in-network deductible waived, but out-of-network still active until 3000.00 is hit.
This tracks: out-of-network has a higher threshold since it's a higher deductible tier. Applying this to Claim 1's result of A having 2100.00 applied from out-of-network — that crosses the 1500.00 in-network mark but not the 3000.00 out-of-network mark. So A's in-network deductible is now satisfied (2100.00 >= 1500.00), while out-of-network isn't (2100.00 < 3000.00). For Claim 3, since it's in-network for A, the deductible should be satisfied.
before: 2100.00 (from Claim 1), in-network threshold 1500.00 already met, so no additional deductible applies to Claim 3. Balance stays at 2100.00, member owes just the 360.00 coinsurance.
For Claim 4 (out-of-network for A): balance is still 2100.00, but out-of-network threshold is 3000.00 - since 2100.00 < 3000.00, deductible still applies here. Remaining amount needed: 3000.00 - 2100.00 = 900.00.
With allowed amount 1600.00, deductible takes 900.00, leaving 700.00 for 40% coinsurance = 280.00. Member cost share totals 1180.00, plan pays 420.00 (60% of 700.00). Deductible balance now hits 3000.00.
This corrects my earlier assumption - Claim 4 actually has 900.00 applied to deductible, not 0.00. Need to redo the OOPM calculation with this correction.
OOPM tracking:
- A after Claim 3: 3120.00 + 360.00 = 3480.00
- Family after Claim 3: 4420.00 + 360.00 = 4780.00
- A after Claim 4: 3480.00 + 1180.00 = 4660.00
- Family after Claim 4: 4780.00 + 1180.00 = 5960.00
Family deductible progression: 900.00 after Claim 1 (unchanged, out-of-network), then 2200.00 after Claim 2 (900.00 + 1300.00).
- After Claim 3: stays 2200.00 (A's individual deductible already satisfied)
- After Claim 4: stays 2200.00 (out-of-network)
Final ending family deductible: 2200.00
Claim 4 answer:
- member_responsibility: 1180.00
- plan_paid: 420.00
- deductible_applied: 900.00
- copay_amount: 0.00
- coinsurance_amount: 280.00
Ending accumulators:
- ending_deductible_a: 3000.00
- ending_oopm_a: 4660.00
- ending_deductible_b: 1300.00
- ending_oopm_b: 1300.00
: a member satisfies their own deductible independently, or the family deductible satisfies everyone once total family credits hit 3000.00.
"Total family credits" means summing deductible credits across all members regardless of who incurred them. So A's 2100.00 counts toward both A's individual deductible and the family total.
But wait — Claim 1's 2100.00 is out-of-network, so it likely doesn't apply toward the in-network family deductible tracking at all.
Let me trace through each claim:
- Claim 1: A gets 2100.00 (out-of-network, excluded from family deductible) → family stays at 900.00
- Claim 2: B gets 1300.00 (in-network) → family becomes 900.00 + 1300.00 = 2200.00
- Claim 3: A's deductible already satisfied, nothing new applied → family stays 2200.00
- Claim 4: A gets 900.00 more (out-of-network, excluded) → family stays 2200.00
So 2200.00 as the ending family deductible checks out. Now I need to verify Claim 3 more carefully.
After Claim 1, A's balance is 2100.00. Since in-network threshold is 1500.00 and 2100.00 exceeds that, no more deductible applies to in-network services for A - only coinsurance kicks in. Claim 3 is in-network, so A's balance stays at 2100.00, confirming my earlier calculation.
But I should double check whether the family deductible still factors into Claim 3. After Claims 1-2: family deductible balance is 2200.00 (only in-network credits count), threshold 3000.00, remaining 800.00.
A's individual in-network deductible is already satisfied (2100.00 >= 1500.00). With embedded structure, a member's obligation ends once either their individual or the family threshold is met - though the family total keeps accumulating regardless.
So for Claim 3, A's individual deductible is satisfied, meaning no deductible applies even though the family deductible remains unmet - A simply stops contributing further.
Family deductible stays at 2200.00 after this claim.
For Claim 4, since A crossed out-of-network territory, they'd need to hit that separate 3000.00 threshold - so 900.00 in additional deductible would apply there.
Let me double-check this logic once more since I keep going back and forth. The embedded deductible structure works like this: individual deductibles (say 1500.00 each) and a family deductible (say 3000.00 combined) run in parallel. Deductible applies to a member's claims until either their personal threshold is hit or the family threshold is hit - whichever comes first. Once satisfied, that member
accumulator gets checked against the threshold relevant to the claim type—1500.00 for in-network, 3000.00 for out-of-network.
So A's 2100.00 balance clears the in-network threshold but falls short of the out-of-network one. That means A still owes deductible on out-of-network claims even though in-network is done. Makes sense given the higher out-of-network threshold.
For Claim 4: deductible applied 900.00 (hits 3000.00 out-of-network threshold), coinsurance 280.00 on remaining 700.00, member cost share 1180.00, plan pays 420.00. Ending accumulators: A's deductible 3000.00 (satisfied), A's OOPM 4660.00, family deductible stays 2200.00, family OOPM 5960.00.
Wait—json{
"member_responsibility": 640.00,
"plan_paid": 960.00,
"deductible_applied": 0.00,
"copay_amount": 0.00,
"coinsurance_amount": 640.00,
"ending_deductible_a": 3000.00,
"ending_oopm_a": 4120.00,
"ending_deductible_b": 1300.00,
"ending_oopm_b": 1300.00,
"ending_family_deductible": 2200.00,
"ending_family_oopm": 5420.00
}
Grader detail
json{
"fields": [
{
"field": "member_responsibility",
"want": 640,
"got": 640,
"ok": true,
"present": true
},
{
"field": "plan_paid",
"want": 960,
"got": 960,
"ok": true,
"present": true
},
{
"field": "deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "coinsurance_amount",
"want": 640,
"got": 640,
"ok": true,
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},
{
"field": "ending_family_deductible",
"want": 3000,
"got": 2200,
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 4380,
"got": 5420,
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 3000,
"got": 3000,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 4120,
"got": 4120,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 0,
"got": 1300,
"ok": false,
"present": true
},
{
"field": "ending_oopm_b",
"want": 260,
"got": 1300,
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}Reasoning · 15,630 tokens
Let me work through this step by step.
The plan document tells me:
- Individual in-network deductible: $1500.00
- Family in-network deductible: $3000.00
- Embedded structure
- Individual out-of-network deductible: $3000.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance
- Individual in-network OOPM: $6000.00
- Family in-network OOPM: $12000.00
- Individual out-of-network OOPM: $12000.00
- Coinsurance after deductible, in-network: 20% member / 80% plan
- Coinsurance after deductible, out-of-network: 40% member / 60% plan
- Copays do NOT credit the deductible
- Copays always credit the out-of-pocket maximum
Starting accumulators:
- A: deductible $900.00, OOPM $900.00
- B: deductible $0.00, OOPM $0.00
- Family: deductible $900.00, OOPM $900.00
Let me adjudicate each claim:
**CLAIM 1 — 2026-05-05 — A (subscriber)**
- Service: Out-of-network specialist procedure
- Network: Out-of-network
- Billed: $4440.00
- Allowed: $2400.00
A is out-of-network. The out-of-network individual deductible is $3000.00.
A's current deductible accumulator: $900.00
A's deductible remaining: $3000.00 - $900.00 = $2100.00
Family deductible remaining: $3000.00 - $900.00 = $2100.00
For an embedded structure with out-of-network, I need to think about this carefully.
The document specifies that in-network and out-of-network credits share a single balance for each member, but the threshold to satisfy differs by network. A's balance is $900.00 regardless of network; when the service is out-of-network, that balance is measured against $3000.00.
So A's remaining deductible for this claim is $3000.00 - $900.00 = $2100.00.
The allowed amount on this claim is $2400.00. Since the remaining deductible ($2100.00) is less than the allowed amount, the full $2100.00 goes toward deductible, leaving $300.00 to which the 40% out-of-network coinsurance applies.
insurance: $300.00 × 0.40 = $120.00 owed by member, $180.00 paid by plan.
Total member cost for Claim 1: $2100.00 + $120.00 = $2220.00. Plan pays $180.00.
Updated accumulators:
- A's deductible: $3000.00 (met)
- A's OOPM: $3120.00
- Family deductible: $3000.00 (met)
- Family OOPM: $3120.00
Moving to Claim 2 (2026-05-21, spouse B, in-network outpatient imaging).
Billed $2405.00, allowed $1300.00. B's individual deductible is $1500.00, currently at $0.00.
Even though family deductible is satisfied, B's individual deductible can still accumulate separately, leaving $1500.00 remaining for B.
The full $1300.00 allowed amount applies toward B's deductible, leaving $0.00 of the allowed amount and no room for coinsurance on this claim.
Member owes $1300.00, plan pays $0.00 for Claim 2.
Updated accumulators: B deductible $1300.00, B OOPM $1300.00, A deductible unchanged $3000.00, A OOPM unchanged $3120.00, family deductible stays satisfied at $3000.00, family OOPM increases to $4420.00.
Moving to Claim 3 (2026-06-14) for A — in-network follow-up procedure, billed $3330.00, allowed $1800.00. A is in-network with individual deduct
ible of $1500.00. A's accumulator shows $3000.00, already satisfied, and family deductible is also satisfied at $3000.00. Applying 20% coinsurance to the $1800.00 allowed amount: member owes $360.00, plan pays $1440.00. Updated OOPMs: A rises to $3480.00, family to $4780.00. Next up is Claim 4 (2026-07-08) for A, an out-of-network diagnostic study.
Billed: $2960.00
- Allowed: $1600.00
Since A is out-of-network, I need to double check the deductible rules — checking the plan document, deductible credits from both in-network and out-of-network accumulate into a single balance, but the threshold differs depending on service type: $1500 individual/$3000 family in-network, versus $3000 individual out-of-network. So a member's
Reconsidering: each member has one running deductible balance. In-network claims apply the $1500 threshold, out-of-network claims apply the $3000 threshold, but all credits feed the same accumulator regardless of service type.
For Claim 1, A's balance sits at $900. Since this is out-of-network, the target is $3000, leaving $2100 remaining. With an allowed amount of $2400, deductible absorbs $2100, leaving $300 for coinsurance — split 40/60 as $120 member / $180 plan.
Member total: $2100 + $120 = $2220. Plan pays $180.
Updated after Claim 1:
- A deductible: $3000.00 ✓ (met)
- A OOPM: $3120.00
- Family deductible: $3000.00 ✓
- Family OOPM: $3120.00
This checks out against my prior work. Moving to Claim 4, after Claims 2 and 3 have already brought A's deductible to $3000 and OOPM to $3480.
**CLAIM 4 — 2026-07-08 — A (subscriber)** [FINAL]
Out-of-network diagnostic study, allowed $1600.00.
A's deductible balance is $3000.00 - $3000.00 = $0.00, so deductible is fully satisfied. Coinsurance applies at 40% member / 60% plan for out-of-network.
Member coinsurance: $1600 × 0.40 = $640.00
Plan coinsurance: $1600 × 0.60 = $960.00
No deductible applies here since it's already met.
Updating accumulators — A's OOPM goes from $3480 to $4120, family OOPM goes from $4780 to $5420. I need to check whether these track against in-network or out-of-network OOPM limits, since the policy separates individual/family OOPM for in-network vs out-of-network categories.
Individual out-of-network limit is $12000, but there's no explicit family out-of-network figure listed. This makes me wonder if in-network and out-of-network accumulate separately - each type of service counting only toward its matching OOPM.
Rereading the numbers again to be sure I'm not misinterpreting the structure.
Family in-network OOPM: $12000
Without explicit separation, I'll assume in-network and out-of-network accumulate separately, following standard plan design where out-of-network costs (like the $12000 individual limit) run higher than in-network ($6000). Services likely only count toward their respective network's OOPM.
ulator per member for each network type, and once reached, the plan covers 100% for that category.
Looking again: the plan lists individual in-network ($6000), family in-network ($12000), and individual out-of-network ($12000), but no family out-of-network figure. This could mean the family out-of-network OOPM either doesn't exist separately or mirrors the in-network family value.
Rather than getting stuck on this ambiguity, I'll assume a combined OOPM structure and apply the relevant limit based on network status.
network services, the individual OOPM is $12000
- For family out-of-network, I'll assume it's $12000
The starting accumulator just says "out-of-pocket" without specifying in-network or out-of-network, so I should probably track a single OOPM value. Checking the required output keys - I see ending_deductible_a and ending_oopm_a are needed, which supports using one combined accumulator per person rather than splitting by network status.
Copays don't credit deductible but do credit OOPM - confirming a single accumulator per member across all cost-share types. So there's one OOPM balance per member, but the limit that applies depends on which network's service is being processed. The $900 starting balance likely represents accumulated cost-share so far, without network distinction, and each new service adds to this balance, triggering 100% coverage once the balance hits whatever limit applies to that service's network.
This raises ambiguity: if a member's balance hits $6500 (past in-network's $6000 cap) but under out-of-network's $12000 cap, do they still pay coinsurance for out-of-network care? The cleaner interpretation might be separate accumulators per network, each with its own limit and 100%-coverage trigger - but this complicates how I treat the starting $900.
Standard insurance practice typically uses a single combined OOPM, sometimes with a lower in-network sublimit nested inside the overall max.
Given the plan explicitly lists separate in-network ($6000) and out-of-network ($12000) individual OOPMs, I'll treat these as genuinely separate tracks, checking claim 1 for A: an out-of-network service costs $2220, added to the $900 starting balance gives $3120, still well under the $12000 out-of-network limit.
Claim 3 for A is in-network with a $360 cost share. If in-network and out-of-network accumulate separately, A's in-network OOPM would need its own starting point—but only one $900 starting accumulator was given per member. This is the crux of the ambiguity: do both OOPM types share the same running total, or does each start fresh at $900?
If shared, claim 3 brings A's total to $3480 (still under both limits). Claim 4, another out-of-network claim, would continue accumulating in this same combined total against whichever limit applies.
If separate accumulators exist, I'd need to know how much of the initial $900 applies to each network type, which isn't specified—suggesting the single running-total interpretation is more likely intended, with the limit checked against the service's own network type at each step.
Since the output schema only asks for one "ending_oopm_a" value, this confirms there's a single combined accumulator per member rather than separate in/out-of-network trackers. Checking the plan document's OOPM section for how it defines crossing the threshold when different network limits apply to the same running total.
future out-of-network services, but in-network claims still require cost sharing until $6000 is hit.
Maybe simpler: each network type has its own limit tracked against the same accumulator. So I'll treat in-network as capped at $6000 and out-of-network at $12000, checking against whichever limit applies to that claim's network type.
For A:
- Start: $900
- Claim 1 (OON): $900+$2220=$3120, still under $12000 OON cap
- Claim 3 (in-network): $3120+$360=$3480, still under $6000 in-network cap
If a later in-network claim pushes past $6000 (e.g., $2600 cost share on top of $3480 = $6080), the member should only pay up to $6000, then the plan covers 100% for the remainder of that claim.
For claim 4 (out-of-network, $640 cost share): room before hitting $12000 is $8520, so since $640 < $8520, the member pays the
full amount, bringing A's accumulator to $4120.
Checking the family OOPM: before claim 4 it was $4780, adding $640 brings it to $5420 - still under $12000, no cap adjustment needed. Now I should double-check the family accumulator structure since the plan lists separate individual/family limits by network.
individual OOPMs reaches $12000, and the out-of-network family OOPM likely follows the same pattern but isn't clearly stated—possibly $24000 if doubled, or matching the $12000 figure shown. Since the document doesn't separate accumulators by network type, I'll treat it as a single family OOPM tracker, using $12000 as the in-network limit and assuming the out-of-network cap isn't clearly specified.
For Claim 4: member owes $640.00, plan pays $960.00, deductible applied is $0 (already met), no copay applies, coinsurance is $640.00.
Updated totals: A deductible stays at $3000.00, A OOPM rises to $4120.00, B deductible and OOPM remain at $1300.00, family deductible holds at $3000.00, family OOPM moves to $5
640.00, plan_paid $960.00, deductible_applied $0.00, coinsurance $640.00. Ending balances: deductible_a $3000, oopm_a $4120, deductible_b $1300, oopm_b $1300, family_deductible $3000, family_oopm $5420.
Let me verify claim 3 once more. After claim 1, A's deductible sits at $3000, matching the out-of-network threshold exactly, so nothing remains to apply toward the in-network deductible for claim 3.
For claim 3 (in-network), A's accumulator ($3000) already exceeds the $1500 threshold, confirming the deductible is fully satisfied. So the full $1800 allowed amount goes to coinsurance, matching my earlier math.
Rereading the embedded deductible language: individuals satisfy their own deductible independently, while the family deductible is met whenever total family credits reach the family amount — whichever happens first.
So in-network individual is $1500, family is $3000. Once satisfied, that party moves to coinsurance. Claim 1 applied $2100 toward A — but I need to double check whether that $2100 applies against the $1500 in-network threshold or the $3000 out-of-network threshold, since I'm second-guessing which applies here.
credits, satisfied at $1500 for in-network claims or $3000 for out-of-network claims. There's also a family deductible of $3000 that likely applies once total family credits hit that threshold, with embedded logic meaning individual deductibles are satisfied first before the family level kicks in.
Let me trace through claim 1 with this framework:
- A's balance starts at $900 (out-of-network), threshold $3000, remaining $2100
- Family balance also $900, remaining $2100
- Allowed amount is $2400
- Deductible applied = min($2400, $2100, $2100) = $2100
That leaves $300 subject to coinsurance: $300 × 0.40 = $120
Member owes $2100 + $120 = $2220
After this claim, both A's individual balance and the family balance hit $3000 — thresholds satisfied. This confirms my earlier result.
For claim 2:
- B's individual balance is $0, in-network threshold $1500, remaining $1500
- Family balance already at $3000 (satisfied), so family remaining is $0
- Allowed amount $1300
- Deductible applied = min($1300, $1500, $0) = $0 since family remaining caps it
This seems off — the family deductible being exhausted means no further deductible applies even though B's individual deductible isn't met yet.
Re-reading the embedded structure: "individual satisfies the individual deductible on their own; the family deductible is also satisfied once total family credits reach the family amount, whichever comes first." This suggests a member's deductible is satisfied by hitting either their individual amount or the family amount, whichever occurs first. Once satisfied, that member moves to coinsurance.
So once the family deductible is met, all members — including B who hasn't hit their own individual threshold — should be treated as deductible-satisfied. Applying that logic to B's claim now.
cap - once family credits hit $3000, all members shift to coinsurance only.
For Claim 2: B's individual remaining is $1500, but family remaining is $0 since A's claim already satisfied it. This means B owes no further deductible—the family cap overrides B's unmet individual amount, so B moves straight to coinsurance.
Deductible applied: $0, coinsurance applies to the full $1300 allowed amount.
That contradicts what I just calculated. Rereading the definition: "the family deductible is also satisfied once total family credits reach the family amount, whichever comes first" — this means individual deductibles still apply independently, but the family deductible acts as an overall cap satisfied first if reached.
So for B in Claim 2, individual deductible remaining is still $1500, and I need to check whether family credits have already hit $3000.
Given Claim 1 presumably contributed some amount toward the family deductible, if the family total has reached $3000, B owes $0 deductible and moves straight to coinsurance:
- Allowed amount: $1300
- Coinsurance (20%): $260
- Member responsibility: $260
- Plan paid: $1040
This contradicts my prior draft showing member owing the full $1300 — that must have been an error mixing up deductible logic. I need to restart the calculation from the actual starting accumulator values given for A and B before applying Claim 1 and Claim 2 in sequence.
remaining: $2100. Family remaining also $2100. Deductible applied: min($2400, $2100, $2100) = $2100, leaving $300 subject to 40% coinsurance = $120. Member owes $2100 + $120 = $2220; plan pays $180.
Updated accumulators: A's deductible hits $3000 (maxed), B stays at $0, family accumulator moves to $3000 too.
For Claim 2 (B's in-network), family deductible is already satisfied ($0 remaining), so no deductible applies despite B's individual threshold being $1500. Allowed $1300 goes straight to 20% coinsurance: member pays $260, plan pays $1040. B's deductible accumulator stays $0.
Totals so far: Claim 1 member $2220/plan $180; Claim 2 member $260/plan $1040; Claim 3 member $360/plan $1440; Claim 4 member $640/plan $960. Checking these sum correctly against allowed amounts—Claim 1: $2220+$180=$2400 ✓, Claim 2: $260+$1040=$1300 ✓, Claim 3: $360+$1440=$1800, verifying this matches.
With confirmed values, tracking OOPM progression: A starts at $900 pre-existing, adding $2220 from Claim 1 brings A to $3120, same for family total. Claim 2 pushes B's OOPM from $0 to $260, family climbs to $3380. Claim 3 adds $360 to A ($3480) and family ($3740). Claim 4's $640 brings A to $4120, family to $4380.
For deductible tracking though, I need to reconsider B's deductible. I initially had ending_deductible_b at $1300, but since family deductible was already satisfied before Claim 2, no deductible applied there—meaning B's deductible stays at $0. That seems inconsistent with what I calculated before, so I need to check this discrepancy.
The core question is whether family deductible satisfaction exempts individuals from their own deductible tracking. Rereading the embedded structure definition: an individual satisfies their deductible independently, OR the family deductible gets satisfied once total family credits reach the family amount—whichever happens first. Once either triggers, coinsurance applies instead of further deductible.
So for A: Claim 1 applies $2100 toward both individual and family deductible simultaneously.
For B: Claim 2 comes after the family deductible is already satisfied by A's payment, so B applies $0 toward their individual deductible and owes coinsurance on the full allowed amount. B's deductible accumulator should remain $0 since no credits were ever applied to their claims.
Looking at the starting accumulators—A at $900, family at $900—it seems A had already satisfied part of the deductible before Claim 1, whether from earlier claims or a prior period in this scenario. Either way, since B never had deductible applied, B's ending accumulator stays $0.
What's less clear is the relationship between A's individual deductible and the family deductible. The plan lists a $1500 in-network / $3000 out-of-network individual deductible alongside a $3000 family deductible, with an embedded structure. This means each member has their own deductible, but the family deductible can be satisfied by combined claims across A and B. Once A's individual threshold is met, or the family threshold is met, that governs how costs get treated going forward.
For Claim 1, A's $2100 goes toward both A's individual out-of-network deductible and the family deductible—leaving $900 remaining on each. For Claim 2, B's claim hits an already-satisfied family deductible, so $0 applies toward B's individual deductible, and B owes coinsurance on the full allowed amount. B's individual accumulator likely stays untouched since no deductible was actually applied.
So ending_deductible_a: 3000.00, ending_deductible_b: 0.00, ending_family_deductible: 3000.00 — assuming "ending_deductible" means the satisfied amount, not remaining. Now I want to double-check the starting accumulators (A: 900, B: 0) against the family deductible starting point to make sure my math on Claim 1 lines up correctly.
to Claim 2 - their accumulator stays at $0.
The three accumulators operate independently: A's individual, B's individual, and family. Satisfying the family deductible halts deductible collection for everyone, even if individual accumulators haven't caught up.
Final values:
- ending_deductible_a: 3000.00
- ending_deductible_b: 0.00
- ending_family_
deductible: 3000.00
Wait, checking the starting accumulators again - A had 900, B had 0, family had 900 - this matches since family = A + B before any claims. That's consistent, so no issue there.
After Claim 1, A's deductible reaches 3000 (their individual max), B stays at 0, json{
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"ending_oopm_b": 260.00,
"ending_family_deductible": 3000.00,
"ending_family_oopm": 4380.00
}
Grader detail
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}0DeepSeek V3.2 · DeepSeek5.1s · 149 out | 5.4s · 150 out | 6.5s · 148 out
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Grader detail
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Grader detail
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Grader detail
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