Mid-year plan change, accumulators do not carry

The problem is about a health plan adjudication with a mid-year plan change.
The claim is processed with accumulators starting at zero on 2026-07-01.

Deductible applied: 1,500.00  
Coinsurance amount: 900.00  
Member responsibility: 2,400.00  
Plan paid: 0.00  
Ending member deductible: 0 (since the deductible is satisfied)

Let me double-check the coinsurance calculation. The remaining balance after the deductible is 900.00, and 20% of that is 180.00, so the member responsibility should be 1,680.00 and the plan paid 720.00. The ending member deductible should be 0.00 because the deductible is satisfied.

The problem says "ending_member_deductible" and the glossary says "the running year-to-date total of a member's deductible or OOPM." So it should be the accumulator value, which is 1,500.00.

But in the calculation, 1,500.00 is applied, so the ending should be 0.00 if it's the remaining.

I think the key is "ending_member_deductible" is the remaining deductible after the claim.

In many adjudication systems, they report the remaining deductible.

The problem says "ending_member_deductible" and the prior is "Deductible credited" which is the accumulator.

But the key name is "ending_member_deductible" not "ending_member_deductible_accumulator".

I think it's remaining.

Let's see the required keys:

"ending_member_deductible" number

I think it's remaining, because if it was the accumulator, they would say ending_member_deductible_accumulator or something.

In the family rules, they talk about remainder.

I think ending_member_deductible is the remaining deductible after the claim.

So ending 0.

**Analyzing the Impact of a Mid-Year Plan Design Change on Member Accumulators**

My primary concern here is understanding how a mid-year plan design change affects a member's accumulated progress towards their deductible and out-of-pocket maximum. The key piece of information is that the group opted *not* to purchase an accumulator carryover rider when they switched their plan design, which became effective on July 1, 2026. This is critical because, without that rider, any deductible and out-of-pocket credits the member had accumulated under the *old* plan design are extinguished. They essentially start from zero on the new plan's effective date.

So, even though this member had met their $1500.00 deductible and their $2240.00 out-of-pocket maximum by June 30, 2026, under the previous plan, all of that progress is wiped clean as of July 1, 2026. Their accumulators for both deductible and OOPM reset to $0.00.

Now, I need to evaluate a specific claim with a Date of Service (DOS) of August 6, 2026. This is an in-network outpatient surgery claim, and it's subject to deductible and coinsurance. The allowed amount for this service is $2400.00.

As of August 6, 2026, *before* this claim is processed, the member's accumulators are at:
*   Deductible: $0.00
*   Out-of-Pocket Maximum (OOPM): $0.00

The individual deductible threshold for the new plan is $1500.00.
The allowed amount is $2400.00.
To determine the amount applied to the deductible, I take the minimum of the allowed amount and the remaining deductible needed: `min($2400.00, $1500.00 - $0.00)`, which equals $1500.00.

After applying the deductible, the remaining allowed amount is $2400.00 - $1500.00 = $900.00.

Now I consider the coinsurance. For in-network services after the deductible has been met, the split is 20% for the member and 80% for the plan.
The member's coinsurance amount is 20% of the remaining allowed amount: `$900.00 * 0.20 = $180.00`.

The total member responsibility for this claim, therefore, is the deductible amount plus the coinsurance amount: `$1500.00 + $180.00 = $1680.00`.

I also need to check this against the individual in-network out-of-pocket maximum, which is $6000.00. The member's responsibility of $1680.00 is well below this $6000.00 limit, so the OOPM is not reached by this single claim.

The plan's payment for this claim will be the remaining allowed amount after the member's responsibility is covered: `$2400.00 - $1680.00 = $720.00` (or, alternatively, 80% of the $900.00 remaining after deductible: `$900.00 * 0.80 = $720.00`).

Finally, the member's deductible accumulator at the end of processing this claim will be the amount applied to the deductible: $1500.00.

To recap the key figures for this claim, based on the new plan design and the absence of a carryover rider:
*   The amount applied to the deductible is $1500.00.
*   The coinsurance amount the member is responsible for is $180.00.
*   The total member responsibility for this claim is $1680.00.
*   The plan paid $720.00 for this claim.
*   The member's ending deductible accumulator, after this claim, is $1500.00.

I've re-verified that the mid-year plan change provision explicitly states that accumulators reset to zero because the carryover rider was not purchased. This confirms my calculation that the prior progress is indeed lost. I also noted there were no copays mentioned for this claim, only deductible and coinsurance, so I didn't need to account for those. Everything appears to be consistent.

**Understanding the Impact of Plan Design Changes on Member Accumulators and Claims**

My thought process here is to meticulously trace the financial implications of a plan design change on a specific member's benefits. The core issue is the effective date of a new plan design – July 1, 2026 – and the critical fact that the group *did not* purchase the accumulator carryover rider. This immediately tells me that any accumulated progress towards deductibles and out-of-pocket maximums made by the member *prior* to this effective date will be lost. Essentially, their accumulators will reset to zero on July 1, 2026.

Now, let's consider the member's situation *before* the plan change. I see they had already met their $1,500 individual deductible and had $2,240 credited towards their out-of-pocket maximum. However, because of that crucial lack of a carryover rider, all of that progress is wiped clean as of July 1, 2026. Therefore, on the date of service (DOS) of August 6, 2026, their deductible accumulator stands at $0.00, and their out-of-pocket maximum accumulator is also $0.00. This is the foundational piece of information that drives the entire claim adjudication.

Next, I examine the claim itself, dated August 6, 2026. It's for an in-network outpatient surgery, which means both the deductible and coinsurance provisions will apply. The allowed amount for this service is $2,400.00.

**Step 1: Deductible Application.** My first task is to apply the deductible. The member's individual in-network deductible is $1,500.00. Since their deductible accumulator is $0.00 (as established by the plan change), the member will be responsible for the full $1,500.00 towards this deductible. After applying the deductible, the remaining allowed amount for the service is $2,400.00 - $1,500.00 = $900.00.

**Step 2: Coinsurance Calculation.** With the deductible satisfied, I move to coinsurance. The plan specifies an in-network coinsurance split of 20% for the member and 80% for the plan. Therefore, the member's coinsurance responsibility will be 20% of the remaining allowed amount, which is 20% of $900.00. This calculates to $180.00.

**Step 3: Out-of-Pocket Maximum Consideration.** My next step is to assess if this claim, or the member's accumulated cost-sharing for the year, will hit their out-of-pocket maximum (OOPM). The member's OOPM is $6,000.00. The total cost-sharing for this specific claim is the sum of the deductible paid and the coinsurance: $1,500.00 + $180.00 = $1,680.00. This $1,680.00 is well below the $6,000.00 OOPM, so it doesn't trigger any special OOPM calculations for this single claim. Consequently, the member's total responsibility for this claim is $1,680.00. The plan's responsibility, therefore, is the allowed amount minus the member's responsibility: $2,400.00 - $1,680.00 = $720.00.

**Step 4: Updating Accumulators Post-Claim.** Finally, I need to update the member's accumulators *after* this claim has been processed. The member paid $1,500.00 towards their deductible for this service. Since the accumulators reset to zero on July 1, 2026, their ending member deductible for the plan year (as of this claim) will be $1,500.00. Similarly, their out-of-pocket accumulator would also start accumulating from zero and would now reflect $1,680.00, though this specific detail wasn't requested in the JSON output.

I'll now consolidate these findings into the required JSON format, ensuring all numerical values are represented with two decimal places as requested:
*   `deductible_applied`: $1,500.00
*   `coinsurance_amount`: $180.00
*   `member_responsibility`: $1,680.00
*   `plan_paid`: $720.00
*   `ending_member_deductible`: $1,500.00

**My Thought Process on the Bluebonnet PPO 1500 Claim**

Alright, let's break down this Bluebonnet PPO 1500 claim. My primary concern here is accurately calculating the member's responsibility and the plan's payment, especially considering the mid-year plan design change.

First, I've identified the core plan details for the period relevant to the claim: the Bluebonnet PPO 1500 plan, which runs from January 1, 2026, to December 31, 2026. The key individual in-network benefits are a $1500 deductible and a $6000 out-of-pocket maximum, with a 20% member coinsurance after the deductible is met.

Now, the critical factor is the mid-year plan change provision. It explicitly states that the group *did not* purchase the accumulator carryover rider. This means that any deductibles or out-of-pocket expenses accumulated before July 1, 2026, are irrelevant for claims processed on or after that date. The accumulators effectively reset to zero on July 1, 2026. The previous credits of $1500 towards the deductible and $2240 towards the OOPM from the first half of the year are completely wiped out.

The date of service for this claim is August 6, 2026. Since this date falls after the July 1, 2026 reset date, I will proceed with the calculations assuming the member's accumulators for both deductible and out-of-pocket maximum are at zero at the start of this claim.

The service is an in-network outpatient surgery, which is subject to both deductible and coinsurance. The allowed amount for this service is $2400.00.

Given the plan's in-network deductible of $1500 and the current member deductible accumulator being $0.00, the amount applied to the deductible will be the minimum of the allowed amount ($2400.00) and the remaining deductible ($1500.00). Therefore, $1500.00 is applied to the deductible.

After applying the deductible, the remaining allowed amount for coinsurance calculation is $2400.00 (allowed amount) - $1500.00 (deductible applied) = $900.00.

The member's coinsurance responsibility is 20% of this remaining $900.00, which equals $180.00.

So, the total member responsibility for this claim is the deductible amount plus the coinsurance amount: $1500.00 (deductible) + $180.00 (coinsurance) = $1680.00.

The plan's payment for this claim is the allowed amount minus the member's responsibility: $2400.00 - $1680.00 = $720.00.

Next, I need to update the member's accumulators.
The new member deductible accumulator will be the previous accumulator ($0.00) plus the deductible applied to this claim: $0.00 + $1500.00 = $1500.00. This will be the `ending_member_deductible`.

The new member out-of-pocket maximum accumulator will be the previous accumulator ($0.00) plus the total member responsibility for this claim: $0.00 + $1680.00 = $1680.00. Since this $1680.00 is well below the individual in-network OOPM limit of $6000.00, no OOPM limit is hit.

I've double-checked the calculations for rounding and ensured that the member responsibility plus plan paid equals the allowed amount ($1680.00 + $720.00 = $2400.00). All the key data points, `deductible_applied`, `coinsurance_amount`, `member_responsibility`, `plan_paid`, and `ending_member_deductible`, align with the plan rules and the critical mid-year reset provision. The fact that the group did not purchase the accumulator carryover rider is key, and I've consistently applied the rule that accumulators restart at zero from July 1, 2026. The individual deductible is still $1500, and it has been correctly applied. The formatting and keys for the output are also confirmed.

**My Thought Process for Calculating a Claim Under a Mid-Year Plan Change**

Alright, let's walk through this claim calculation. I'm looking at a scenario where the plan year is January 1st, 2026, to December 31st, 2026, but there's a crucial mid-year plan change effective July 1st, 2026. The key detail here is that the "Accumulator Carryover Rider" was *not* purchased. This immediately tells me that any deductible or out-of-pocket maximum (OOPM) progress made *before* July 1st is irrelevant. All accumulators reset to zero on that effective date.

So, for the period starting July 1st, 2026, the plan design I need to focus on is:
*   In-network Deductible: $1,500.00 (individual)
*   In-network OOPM: $6,000.00 (individual)
*   In-network Coinsurance: 20% for the member, 80% for the plan.
*   Important note: Copays don't count towards the deductible, but they *do* count towards the OOPM.
*   And crucially, my cost share is calculated based on the "Allowed Amount."

Now, I have a specific service date of August 6th, 2026. This is *after* the mid-year reset, so my accumulators are starting from zero. The service is an in-network outpatient surgery, which involves both deductible and coinsurance.

The Allowed Amount for this service is $2,400.00.

Here's how I break down the member's responsibility step-by-step:

1.  **Apply the Deductible:**
    *   My individual deductible for the new plan period (starting July 1st) is $1,500.00.
    *   Since my accumulators are at $0.00, my remaining deductible is $1,500.00.
    *   I compare the Allowed Amount ($2,400.00) with the Remaining Deductible ($1,500.00). I'll apply the *lesser* of the two towards the deductible.
    *   Deductible Applied: $1,500.00.

2.  **Apply Coinsurance:**
    *   After applying the deductible, there's a remaining portion of the Allowed Amount: $2,400.00 - $1,500.00 = $900.00.
    *   This remaining $900.00 is subject to coinsurance. My share is 20%.
    *   Coinsurance Amount (Member): $900.00 * 0.20 = $180.00.

3.  **Check Against the Out-of-Pocket Maximum (OOPM):**
    *   Now I need to see how much of my OOPM this claim is contributing.
    *   My total responsibility for this claim so far is the Deductible Applied ($1,500.00) plus the Coinsurance Amount ($180.00), totaling $1,680.00.
    *   My Year-to-Date (YTD) OOPM accumulation since July 1st is still $0.00.
    *   My individual OOPM limit for the new plan period is $6,000.00.
    *   Since $1,680.00 is well within my remaining OOPM ($6,000.00 - $0.00), the full member responsibility of $1,680.00 will be applied.

4.  **Finalize Totals:**
    *   Member Responsibility: $1,680.00.
    *   Plan Paid: This is the Allowed Amount minus what the member is responsible for. $2,400.00 - $1,680.00 = $720.00. I double-check this by looking at the plan's 80% coinsurance on the remaining $900.00, which is indeed $900.00 * 0.80 = $720.00. It matches.

5.  **Ending Accumulators:**
    *   My individual deductible for the current plan period (since July 1st) is now fully met.
    *   Ending Member Deductible: $1,500.00.

So, to summarize the financial outcome of this specific claim, formatted as requested:
*   `deductible_applied`: 1500.00
*   `coinsurance_amount`: 180.00
*   `member_responsibility`: 1680.00
*   `plan_paid`: 720.00
*   `ending_member_deductible`: 1500.00

The explicit note about the mid-year plan change and the lack of an accumulator carryover rider was the absolute linchpin here, making any prior benefit period activity completely null and void for this calculation. The calculation itself is straightforward once that key rule is applied. No complex rounding was necessary as all values were clean.

**My Thought Process on This Bluebonnet PPO 1500 Claim**

Alright, let's break down this Bluebonnet PPO 1500 situation. I'm going to walk through my logic, step-by-step, just as I would if I were analyzing this in real-time.

First, I need to establish the baseline plan details for the Bluebonnet PPO 1500 plan. The period we're looking at is from January 1, 2026, to December 31, 2026. For an individual, the deductible is set at $1,500. This is an "embedded" structure, which means the individual deductible applies before the out-of-pocket maximum (OOPM). The coinsurance is a standard 20% for the member and 80% for the plan, but only once the deductible has been met. The individual OOPM is $6,000.

Now, here's the critical piece: there was a mid-year plan change that became effective on July 1, 2026. The "MID-YEAR PLAN CHANGE PROVISION" explicitly states that accumulators restart at zero on this effective date because the group did *not* purchase the carryover rider. This is a key point that significantly impacts how I'll calculate this claim.

So, as of July 1, 2026, my member's deductible accumulator is $0.00, and their OOPM accumulator is also $0.00. This means any costs incurred before this date, even if they contributed to the deductible or OOPM for the first half of the year, are irrelevant for claims processed on or after July 1st.

The date of service for the claim I'm evaluating is August 6, 2026. This is well after the July 1 reset, so I'm operating with those zeroed-out accumulators. The service is an in-network outpatient surgery, and it's subject to both the deductible and coinsurance. The allowed amount for this service is $2,400.

Let's apply the deductible first. The individual deductible is $1,500. Since the member's deductible accumulator is currently $0.00, the full $1,500 of the deductible needs to be applied to this claim. The calculation is `min(Allowed Amount, Individual Deductible Remainder)`. In this case, it's `min($2,400.00, $1,500.00 - $0.00)`, which equals $1,500.00.

After applying the deductible, I have a remaining allowed amount of $2,400.00 - $1,500.00 = $900.00.

Next, I apply the coinsurance. The member is responsible for 20% of this remaining allowed amount. So, the coinsurance amount is $900.00 * 0.20 = $180.00.

Now, I can calculate the total member responsibility before checking against the OOPM. This is the deductible amount plus the coinsurance amount: $1,500.00 + $180.00 = $1,680.00.

The next step is to check this against the OOPM. The individual OOPM limit is $6,000.00. As of July 1, 2026, the member's OOPM accumulator was $0.00. My current member responsibility is $1,680.00. Adding this to the accumulator gives me a new OOPM accumulator of $0.00 + $1,680.00 = $1,680.00. This is clearly well below the $6,000.00 limit, so the entire $1,680.00 is the member's responsibility.

The plan's responsibility is the total allowed amount minus the member's responsibility: $2,400.00 - $1,680.00 = $720.00.

Finally, I need to track the ending member deductible accumulator. Since $1,500.00 of the deductible was met by this claim, the ending member deductible accumulator for this period will be $1,500.00.

So, to summarize the outputs based on this calculation:
*   `deductible_applied`: $1,500.00
*   `coinsurance_amount`: $180.00
*   `member_responsibility`: $1,680.00
*   `plan_paid`: $720.00
*   `ending_member_deductible`: $1,500.00

My thought process is essentially: understand the plan structure and limits, identify any critical plan changes (like the mid-year reset), apply the deductible first based on the current accumulator, calculate the remaining balance, apply coinsurance to that balance, sum up member costs, check against the OOPM, determine plan payment, and finally update the relevant accumulators. The mid-year reset was the most crucial factor in making sure I didn't carry over any prior deductible or OOPM amounts.

Alright, I've got this outpatient surgery claim to adjudicate, and it's a single one, which simplifies things considerably. My plan of action is pretty straightforward: First, I need to nail down the member's financial standing at the exact moment this claim occurred, paying close attention to that "MID-YEAR PLAN CHANGE PROVISION" they mentioned. Once I've got that sorted, I'll proceed with adjudicating the claim itself by applying the deductible and then the coinsurance to whatever's left. I'll sum up the total the member owes and figure out how much the plan needs to pay. Then, as a final step before outputting the results, I'll update the member's accumulators with the impact of this processed claim. Finally, I'll package all these calculated values into the required JSON format.

Let's dive into **Step 1: Determining the member's financial state.**

The plan in question is the "Bluebonnet PPO 1500," and the date of service for this claim is August 6, 2026. Now, here's the crucial detail: there was a mid-year plan change that took effect on July 1, 2026. The "MID-YEAR PLAN CHANGE PROVISION" is crystal clear on this: if a group switches plan designs mid-year, any deductible and out-of-pocket credits earned under the old design *do not* carry over *unless* they've specifically purchased an accumulator carryover rider. This group, however, has *not* purchased that rider. The provision explicitly states that "Accumulators restart at zero on the effective date of the new design." This is the linchpin of my entire adjudication. It means all the progress the member might have made towards their deductible and out-of-pocket maximum from January 1st to June 30th is effectively wiped clean. So, as of July 1, 2026, when the new plan design kicked in, the member's accumulators were reset to zero. Therefore, for this claim occurring on August 6, 2026, I'll be working with these reset accumulators: zero credited towards the deductible and zero credited towards the out-of-pocket maximum.

Now, onto **Step 2: Adjudicating the claim.**

Here are the specifics for this claim:
*   Date of Service: August 6, 2026
*   Service: This is an in-network outpatient surgery, which means it's subject to both the deductible and coinsurance.
*   Allowed Amount: The total allowed amount for this service is $2400.00.

And here are the relevant plan benefits for this type of service:
*   In-network Individual Deductible: $1500.00
*   In-network Coinsurance: The member is responsible for 20%, and the plan covers 80%.

Now, let's walk through the calculation:

*   **Deductible:**
    *   The member's remaining deductible at the start of this claim is $1500.00, remember, it was reset to zero.
    *   The allowed amount for the claim is $2400.00.
    *   Since the allowed amount ($2400.00) is greater than the member's remaining deductible ($1500.00), the entire deductible will be applied.
    *   So, `deductible_applied` is **$1500.00**. This satisfies the individual deductible for the plan year.

*   **Coinsurance:**
    *   The amount that is now subject to coinsurance is the remaining portion of the allowed amount after the deductible has been applied.
    *   Amount subject to coinsurance = Allowed Amount - Deductible Applied
    *   Amount subject to coinsurance = $2400.00 - $1500.00 = $900.00.
    *   The member's coinsurance responsibility is 20%.
    *   Therefore, the `coinsurance_amount` is $900.00 * 0.20 = **$180.00**.

*   **Total Member Responsibility:**
    *   This is the sum of the deductible applied and the coinsurance amount.
    *   `member_responsibility` = `deductible_applied` + `coinsurance_amount`
    *   `member_responsibility` = $1500.00 + $180.00 = **$1680.00**.

*   **Plan Payment:**
    *   The plan's payment is the allowed amount minus what the member is responsible for.
    *   `plan_paid` = Allowed Amount - `member_responsibility`
    *   `plan_paid` = $2400.00 - $1680.00 = **$720.00**.
    *   As a cross-check, the plan pays 80% of the coinsurance portion: $900.00 * 0.80 = $720.00. This confirms the calculation.

On to **Step 3: Updating the member's accumulators.**

Before this claim, as of July 1, 2026, the member's accumulators were:
*   Deductible: 0.00
*   OOPM: 0.00

Now, let's account for the credits from this claim:
*   Deductible Credit: $1500.00 (from the `deductible_applied` amount)
*   OOPM Credit: $1680.00 (the total `member_responsibility`, which includes both deductible and coinsurance, contributes to the OOPM)

So, the ending accumulators will be:
*   `ending_member_deductible` = Initial Deductible + `deductible_applied`
*   `ending_member_deductible` = 0.00 + 1500.00 = **$1500.00**. This means the member's individual deductible is now met for the remainder of the plan year.

Finally, **Step 4: Populating the JSON output.**

Based on all these calculations, here are the values I'll be populating into the JSON output:

*   `deductible_applied`: 1500.00
*   `coinsurance_amount`: 180.00
*   `member_responsibility`: 1680.00
*   `plan_paid`: 720.00
*   `ending_member_deductible`: 1500.00

I've double-checked the prompt requirements and the logic. The critical point, the "MID-YEAR PLAN CHANGE PROVISION," was correctly identified and its impact – resetting accumulators to zero – was applied. This significantly simplified the adjudication process, as I didn't need to factor in any prior benefit usage for this plan year. The calculations flow directly from this reset. The $2400 allowed amount first meets the $1500 deductible, leaving $900 subject to the 20% coinsurance. This results in the member paying $1500 plus $180, for a total of $1680, and the plan paying the remaining $720. The ending deductible accumulator correctly reflects the $1500 applied from this claim. Everything aligns.

Alright, let's break down this claim adjudication. My primary task is to process a claim against the "Bluebonnet PPO 1500" plan, but the critical detail here is that the group *changed their plan design mid-year*, specifically on 2026-07-01. This is the linchpin of the entire calculation, and importantly, they *did not* purchase the accumulator carryover rider.

Now, the plan document has a very clear "MID-YEAR PLAN CHANGE PROVISION" that states: "Where a group changes plan design effective mid-year, deductible and out-of-pocket credits earned under the prior design DO NOT carry forward unless the group has purchased the accumulator carryover rider." It further clarifies, "Accumulators restart at zero on the effective date of the new design."

Since this group *has not* purchased that rider, the provision applies directly. The effective date of the new design was 2026-07-01. The claim's date of service is 2026-08-06, which falls *after* this effective date. Therefore, according to the plan, their accumulators for both deductible and out-of-pocket maximum reset to zero on 2026-07-01. This means any deductible or out-of-pocket amounts they may have met under the *prior* plan design in the first half of the year are irrelevant for this claim. Their starting deductible accumulator for this claim is 0.00, and their OOPM accumulator is also 0.00.

Moving on to the claim details and plan benefits:
The service is an in-network outpatient surgery.
The in-network individual deductible is $1500.00.
The in-network coinsurance is 20% member / 80% plan.
The allowed amount for this service is $2400.00.

Now, let's adjudicate step-by-step:

1.  **Deductible Application:**
    *   My starting member deductible accumulator is 0.00.
    *   The remaining deductible needed is $1500.00 (1500.00 - 0.00).
    *   The allowed amount for the service ($2400.00) is greater than the remaining deductible.
    *   Therefore, the full remaining deductible of $1500.00 will be applied to the member's responsibility.
    *   So, `deductible_applied` is $1500.00.
    *   With this application, the member has now satisfied their individual deductible.
    *   The amount remaining on the claim after the deductible is $2400.00 - $1500.00 = $900.00.

2.  **Coinsurance Calculation:**
    *   This remaining $900.00 is now subject to coinsurance.
    *   The member's share is 20%, so $900.00 * 0.20 = $180.00.
    *   This means `coinsurance_amount` is $180.00.

3.  **Total Member Responsibility:**
    *   The total the member is responsible for is the sum of the deductible applied and the coinsurance amount.
    *   `member_responsibility` = $1500.00 (deductible) + $180.00 (coinsurance) = $1680.00.

4.  **Plan Paid Amount:**
    *   The amount the plan pays is the allowed amount minus the total member responsibility.
    *   `plan_paid` = $2400.00 - $1680.00 = $720.00.
    *   As a cross-check, since the deductible was fully met by the member, the plan pays its share of the coinsurance. The plan's share is 80% of the $900.00 coinsurance amount, which is $900.00 * 0.80 = $720.00. This matches.

5.  **Ending Accumulators:**
    *   The claim requires the `ending_member_deductible`.
    *   Starting deductible accumulator was 0.00.
    *   We applied $1500.00 to the deductible for this claim.
    *   Therefore, `ending_member_deductible` is 0.00 + 1500.00 = $1500.00.

So, to summarize my thought process and the final adjudication values: The key was recognizing the mid-year plan change and its impact on accumulator resets, which I've clearly laid out. I then applied the plan's deductible and coinsurance logic to the allowed amount, ensuring the member's responsibility and the plan's payment were calculated correctly based on the current (post-reset) accumulators.

The final values I've determined are:
*   `deductible_applied`: 1500.00
*   `coinsurance_amount`: 180.00
*   `member_responsibility`: 1680.00
*   `plan_paid`: 720.00
*   `ending_member_deductible`: 1500.00

Alright, let's break down this claim adjudication process. My primary objective here is to accurately assess a member's responsibility for a specific service based on their benefit plan.

My mental checklist is already set:
1.  First, I need to get a solid grip on the plan terms that are active for the date of service. This is crucial because plan designs can shift, and knowing the *exact* rules in play is paramount.
2.  Next, I'll pinpoint the member's accumulator balances *before* this claim is processed. These are the starting figures for my calculations.
3.  Then, I'll walk through the claim's adjudication step-by-step, meticulously calculating how much the member owes.
4.  Following that, I'll update those accumulators with the amounts applied from this claim.
5.  Finally, I'll ensure the output is presented precisely as the required keys dictate.

**1. Decoding the Plan Terms:**

The plan year runs from January 1st to December 31st, 2026. Now, here's the critical detail: there was a **mid-year plan change** on July 1st, 2026. The *nature* of the plan design itself remained the same, but importantly, this change *affected the accumulators*.

The specific rule I'm looking at, the `MID-YEAR PLAN CHANGE PROVISION`, is quite explicit: any deductible and out-of-pocket maximum credits earned under the *prior* design *do not carry forward* unless a specific rider was purchased. This group has *not* purchased that rider. This means that the accumulators effectively **restart at zero** on the new design's effective date, which was July 1st, 2026.

The date of service for this claim is August 6th, 2026. Since this date falls *after* the mid-year change, I can confidently conclude that the member's accumulators began anew at 0.00 on July 1st, 2026. Any amounts accumulated prior to that date are simply irrelevant for this claim's calculation.

**2. Establishing Starting Accumulator Values (as of August 6th, 2026, before this claim):**

Based on the mid-year plan change rule, my starting point for this claim is:
*   **Member Deductible:** 0.00
*   **Member OOPM:** 0.00
*   **Family Deductible:** The provided information doesn't include family-level details, so I'll focus solely on the individual member's accumulators for this adjudication.

**3. Adjudicating the Claim Step-by-Step:**

*   **Claim Date:** August 6th, 2026
*   **Service Type:** This is an in-network outpatient surgery, meaning it's subject to the deductible and coinsurance provisions.
*   **Allowed Amount:** The total allowed amount for this service is 2400.00.

Now, let's walk through the calculations:

1.  **Deductible Application:**
    *   The in-network individual deductible is 1500.00.
    *   My current member deductible accumulator is 0.00.
    *   Therefore, the remaining deductible to be met is 1500.00 - 0.00 = 1500.00.
    *   Since the allowed amount (2400.00) is more than the remaining deductible (1500.00), the member will pay the full remaining deductible amount.
    *   This means `deductible_applied` will be 1500.00.

2.  **Coinsurance Calculation:**
    *   After applying the deductible, the amount of the service that now remains and is subject to coinsurance is: 2400.00 (allowed) - 1500.00 (deductible applied) = 900.00.
    *   The member's coinsurance rate for in-network services is 20%.
    *   So, the `coinsurance_amount` is 900.00 * 0.20 = 180.00.

3.  **Total Member Responsibility:**
    *   This is the sum of the deductible that was applied and the calculated coinsurance amount.
    *   `member_responsibility` = 1500.00 (deductible) + 180.00 (coinsurance) = 1680.00.

4.  **Plan Payment Determination:**
    *   The plan covers the portion of the allowed amount that the member is not responsible for.
    *   `plan_paid` = 2400.00 (allowed) - 1680.00 (member responsibility) = 720.00.
    *   As a cross-check, for the amount subject to coinsurance (900.00), the plan pays 80%. So, 900.00 * 0.80 = 720.00. This confirms my calculation.

5.  **Calculating Ending Accumulators:**
    *   **Deductible:** The member's deductible accumulator started at 0.00. We applied 1500.00 from this claim.
    *   So, `ending_member_deductible` = 0.00 + 1500.00 = 1500.00. This means the individual deductible is now satisfied for the remainder of the plan year, effective from July 1st.
    *   **OOPM:** The OOPM accumulator also started at 0.00. Both the deductible applied and the coinsurance amount credited towards the OOPM.
    *   The `ending_member_oopm` accumulator would be 0.00 + 1680.00 = 1680.00. For completeness, I note this is well below the individual OOPM limit (which is 6000.00), so the OOPM is not yet met.

**Summary of Key Calculations for Output:**

*   `deductible_applied`: 1500.00
*   `coinsurance_amount`: 180.00
*   `member_responsibility`: 1680.00
*   `plan_paid`: 720.00
*   `ending_member_deductible`: 1500.00

The absolute linchpin in this entire process is the `MID-YEAR PLAN CHANGE PROVISION`. Had I overlooked that and tried to carry over previous balances, the outcome would have been drastically different: no deductible applied, and the member's coinsurance would have been 2400.00 * 0.20 = 480.00, leading to a much lower member responsibility. But the rule is unequivocally clear: "Accumulators restart at zero on the effective date of the new design."

My calculations have been double-checked:
*   Allowed Amount: 2400.00
*   Deductible to satisfy: 1500.00
*   Amount remaining for coinsurance: 2400.00 - 1500.00 = 900.00
*   Member's coinsurance share: 900.00 * 0.20 = 180.00
*   Total member obligation: 1500.00 + 180.00 = 1680.00
*   Plan's contribution: 900.00 * 0.80 = 720.00
*   Verification: 1680.00 (member) + 720.00 (plan) = 2400.00 (allowed). This confirms the financial balance.
*   Ending deductible accumulator: 0.00 (start) + 1500.00 (applied) = 1500.00. This is correct.

Everything appears to be in order. I can now proceed to format this information into the required JSON structure.

Let me work through this step by step.

The group changed plan design effective 2026-07-01. Accumulators restart at zero because the group has NOT purchased the accumulator carryover rider. So even though the member had 1,500.00 deductible credited and 2,240.00 OOP credited through 6/30, those credits DO NOT carry forward.

Effective 2026-07-01, accumulators restart at zero.

Claim:
- Date of service: 2026-08-06 (after the plan change, so accumulators are at zero)
- Service: In-network outpatient surgery, deductible and coinsurance
- Allowed: 2,400.00

Since it's outpatient surgery (not a copay service like office visit, urgent care, ER, or pharmacy), it's subject to deductible and coinsurance.

In-network individual deductible: 1,500.00
Starting deductible accumulator: 0.00 (reset on 7/1)
Starting OOPM accumulator: 0.00 (reset on 7/1)

Step 1: Apply deductible
- Deductible remaining: 1,500.00
- Claim allowed: 2,400.00
- Deductible applied: min(1,500.00, 2,400.00) = 1,500.00
- Remaining after deductible: 2,400.00 - 1,500.00 = 900.00

Step 2: Apply coinsurance (20% member / 80% plan)
- Coinsurance amount: 900.00 * 0.20 = 180.00
- Plan pays: 900.00 * 0.80 = 720.00

Step 3: Member responsibility
- member_responsibility = 1,500.00 (deductible) + 180.00 (coinsurance) = 1,680.00
- plan_paid = 2,400.00 - 1,680.00 = 720.00

Check: member_responsibility + plan_paid = 1,680.00 + 720.00 = 2,400.00 ✓

Ending member deductible:
- Starting: 0.00
- Applied: 1,500.00
- Ending: 1,500.00 (individual deductible is satisfied)

Let me verify the keys:
- "deductible_applied": 1500.00
- "coinsurance_amount": 180.00
- "member_responsibility": 1680.00
- "plan_paid": 720.00
- "ending_member_deductible": 1500.00

Let me work through this carefully.

Mid-year plan change effective 2026-07-01. The group has NOT purchased the accumulator carryover rider, so accumulators restart at zero on the effective date of the new design.

So as of 2026-07-01:
- Deductible accumulator: 0.00 (restarted)
- OOPM accumulator: 0.00 (restarted)

Wait, let me re-read. "Deductible credited 2026-01-01 through 2026-06-30 .... 1,500.00 (individual satisfied)" and "Out-of-pocket credited over the same period ........... 2,240.00"

But the mid-year plan change provision says credits DO NOT carry forward unless the rider is purchased, and this group has NOT purchased it. "Accumulators restart at zero on the effective date of the new design."

So as of 2026-07-01, the deductible accumulator is 0.00 and the OOPM accumulator is 0.00.

Claim on 2026-08-06:
- In-network outpatient surgery, deductible and coinsurance
- Allowed: 2,400.00

Individual in-network deductible: 1,500.00

Deductible applied: The member needs to satisfy 1,500.00 deductible first.
- Deductible applied: 1,500.00
- Remaining allowed after deductible: 2,400.00 - 1,500.00 = 900.00
- Coinsurance (20% member): 900.00 × 0.20 = 180.00
- Plan pays: 900.00 × 0.80 = 720.00
- Member responsibility: 1,500.00 + 180.00 = 1,680.00
- Plan paid: 720.00

Check: 1,680.00 + 720.00 = 2,400.00 ✓

Ending member deductible: 1,500.00 (individual deductible now satisfied)

OOPM: 0 + 1,680.00 = 1,680.00 (well under the 6,000.00 individual OOPM, so no impact there)

The question asks for ending_member_deductible - this should be 1500.00 (the deductible is now fully satisfied).

Let me work through this step by step.

**Plan Year and Mid-Year Change:**
- Plan year: 2026-01-01 through 2026-12-31
- Group changed plan design effective 2026-07-01
- The plan design above applies both before and after the change; only accumulators are affected.
- The group has NOT purchased the accumulator carryover rider.
- Therefore, accumulators restart at zero on 2026-07-01.

**Accumulators as of 2026-07-01 (after reset):**
- Individual deductible credited: 0.00 (reset from 1,500.00)
- Family deductible credited: 0.00 (reset)
- Individual OOPM credited: 0.00 (reset from 2,240.00)
- Family OOPM credited: 0.00 (reset)

**Claim Details:**
- Date of service: 2026-08-06 (after the mid-year change, so new accumulators apply)
- Service: In-network outpatient surgery, deductible and coinsurance
- Allowed: 2,400.00

**Deductible:**
- Individual deductible (in-network): 1,500.00
- Since accumulators reset on 2026-07-01, the member's deductible accumulator is 0.00 as of the claim date.
- The allowed amount is 2,400.00.
- The member needs to satisfy 1,500.00 of deductible first.
- deductible_applied = 1,500.00

**Coinsurance:**
- After deductible, the remaining allowed amount is 2,400.00 - 1,500.00 = 900.00
- In-network coinsurance: 20% member / 80% plan
- coinsurance_amount = 900.00 * 20% = 180.00

**Member Responsibility:**
- deductible_applied + coinsurance_amount = 1,500.00 + 180.00 = 1,680.00

**Plan Paid:**
- member_responsibility + plan_paid = allowed amount
- plan_paid = 2,400.00 - 1,680.00 = 720.00

**Ending Member Deductible:**
- Starting deductible accumulator: 0.00
- Plus deductible_applied: 1,500.00
- ending_member_deductible = 1,500.00

Let me double-check:
- deductible_applied: 1500.00
- coinsurance_amount: 180.00
- member_responsibility: 1680.00
- plan_paid: 720.00
- ending_member_deductible: 1500.00

Check: member_responsibility (1680.00) + plan_paid (720.00) = 2400.00 = allowed amount. ✓

The deductible is fully satisfied (1500.00 applied against a 1500.00 individual deductible).

All looks correct.

The group changed plan design effective 2026-07-01.
The plan design applies both before and after the change; only the accumulators are affected.
Because the group has NOT purchased the accumulator carryover rider, accumulators restart at zero on the effective date of the new design (2026-07-01).

Claim date of service: 2026-08-06 (after the change).
So, starting accumulators on 2026-07-01:
Individual Deductible: 0.00
Individual OOPM: 0.00

Claim details:
Date of service: 2026-08-06
Service: In-network outpatient surgery, deductible and coinsurance
Allowed: 2400.00

Since the deductible accumulator restarted at 0.00 on 2026-07-01, the member has not met the individual deductible of 1500.00 for the new plan design period.
Wait, the deductible is 1500.00.
Allowed amount: 2400.00.
Deductible applied: 1500.00 (satisfies the individual deductible).
Remaining allowed amount: 2400.00 - 1500.00 = 900.00.
Coinsurance rate for in-network: 20% member / 80% plan.
Coinsurance amount (member's share of the remaining): 900.00 * 20% = 180.00.
Total member responsibility: deductible_applied (1500.00) + coinsurance_amount (180.00) = 1680.00.
Plan paid: 900.00 * 80% = 720.00.
Check: member_responsibility (1680.00) + plan_paid (720.00) = 2400.00. Correct.

Ending member deductible:
Starting deductible: 0.00
Plus deductible applied: 1500.00
Ending member deductible: 1500.00.

Let's double check the "MID-YEAR PLAN CHANGE PROVISION":
"Where a group changes plan design effective mid-year, deductible and out-of-pocket credits earned under the prior design DO NOT carry forward unless the group has purchased the accumulator carryover rider. This group has NOT purchased that rider. Accumulators restart at zero on the effective date of the new design."
So starting 2026-07-01, deductible is 0.
The claim is on 2026-08-06.
Deductible applied = 1500.00
Coinsurance amount = 180.00
Member responsibility = 1680.00
Plan paid = 720.00
Ending member deductible = 1500.00

Let's review the required keys:
"deductible_applied"       number -> 1500.00
"coinsurance_amount"       number -> 180.00
"member_responsibility"    number -> 1680.00
"plan_paid"                number -> 720.00
"ending_member_deductible" number -> 1500.00

Are there any other considerations?
"Coinsurance after deductible, in-network ......... 20% member / 80% plan"
"Deductible Individual (in-network) ................ 1500.00"
Allowed = 2400.00.
Deductible applied = 1500.00.
Remaining = 900.00.
Coinsurance = 900.00 * 0.20 = 180.00.
Member responsibility = 1500.00 + 180.00 = 1680.00.
Plan paid = 900.00 * 0.80 = 720.00.
Ending member deductible = 1500.00.

Looks completely solid.
Formatting numbers as plain numbers with two decimal places:
1500.00
180.00
1680.00
720.00
1500.00
No currency symbols.
JSON format.
No other text.
Done.

The user wants me to adjudicate a claim based on the provided plan document and claim details.

Plan Document: Bluebonnet PPO 1500
Plan year: 2026
Deductible:
  Individual (in-network): 1500.00
  Family (in-network): 3000.00
  Structure: EMBEDDED
Out-of-pocket maximum:
  Individual (in-network): 6000.00
  Family (in-network): 12000.00
Member cost share:
  Coinsurance after deductible, in-network: 20% member / 80% plan

MID-YEAR PLAN CHANGE PROVISION:
  Where a group changes plan design effective mid-year, deductible and out-of-pocket credits earned under the prior design DO NOT carry forward unless the group has purchased the accumulator carryover rider. This group has NOT purchased that rider. Accumulators restart at zero on the effective date of the new design.

Group changed plan design effective 2026-07-01.
Accumulators restart at zero on 2026-07-01.
So, starting deductible accumulator = 0.00
Starting OOPM accumulator = 0.00

CLAIM:
  Date of service: 2026-08-06 (after the mid-year change, so accumulators are 0)
  Service: In-network outpatient surgery, deductible and coinsurance
  Allowed: 2400.00

Calculations:
1. Deductible applied:
   Starting deductible = 0.00
   Individual deductible = 1500.00
   Allowed amount = 2400.00
   Deductible applied = min(1500.00, 2400.00) = 1500.00

2. Remaining allowed amount after deductible:
   2400.00 - 1500.00 = 900.00

3. Coinsurance amount:
   Coinsurance rate = 20% member
   Coinsurance amount = 900.00 * 0.20 = 180.00

4. Member responsibility:
   Deductible applied (1500.00) + Coinsurance amount (180.00) = 1680.00

5. Plan paid:
   Allowed amount (2400.00) - Member responsibility (1680.00) = 720.00
   (Or 900.00 * 0.80 = 720.00)

6. Ending member deductible:
   Starting deductible (0.00) + Deductible applied (1500.00) = 1500.00

Let's double check.
Date of service: 2026-08-06.
Mid-year change effective: 2026-07-01.
Accumulators restart at zero.
So individual deductible accumulator before claim = 0.
Deductible applied = 1500.00.
Coinsurance amount = (2400 - 1500) * 0.20 = 180.00.
Member responsibility = 1500 + 180 = 1680.00.
Plan paid = 2400 - 1680 = 720.00.
Ending member deductible = 1500.00.

Required keys:
  "deductible_applied"       number
  "coinsurance_amount"       number
  "member_responsibility"    number
  "plan_paid"                number
  "ending_member_deductible" number

Values:
deductible_applied: 1500.00
coinsurance_amount: 180.00
member_responsibility: 1680.00
plan_paid: 720.00
ending_member_deductible: 1500.00

Format: plain numbers with two decimal places, no currency symbol.
1500.00
180.00
1680.00
720.00
1500.00

Check rules:
- "Accumulators restart at zero on the effective date of the new design." -> Yes, 0 starting.
- "In-network outpatient surgery, deductible and coinsurance" -> Subject to deductible and coinsurance.
- "Allowed: 2400.00"
- Deductible is 1500.00.
- Coinsurance is 20%.
Everything looks solid.
End of thought.

Let me work through this carefully.

The group changed plan design effective 2026-07-01. The MID-YEAR PLAN CHANGE PROVISION says deductible and OOP credits earned under the prior design do NOT carry forward because the group has not purchased the accumulator carryover rider. Accumulators restart at zero on the effective date of the new design (2026-07-01).

So even though the member had 1,500.00 deductible credited through 2026-06-30 (individual satisfied) and 2,240.00 OOP, those do NOT carry forward. Accumulators restart at zero as of 2026-07-01.

Claim: DOS 2026-08-06, in-network outpatient surgery, deductible and coinsurance apply. Allowed = 2,400.00.

Individual in-network deductible = 1,500.00. Member deductible accumulator = 0.00 as of 2026-07-01 (restart). Family deductible = 3,000.00 — family credits also restart at zero. The member's own deductible applies here.

Deductible applied: the member pays the lesser of their individual remainder and the family remainder. Individual remainder = 1,500.00 (since 0 credited). Family remainder — we don't know other family members' credits post-restart, but presumably 0 as well (family accumulators also restart). The claim is for this member. The member's deductible satisfied by lesser of individual remainder (1,500.00) and family remainder (3,000.00, assuming no other family credits). So deductible applied = 1,500.00.

Remaining allowed after deductible: 2,400.00 - 1,500.00 = 900.00. Coinsurance 20% member = 180.00.

Member responsibility = 1,500.00 + 180.00 = 1,680.00.

Plan paid = 2,400.00 - 1,680.00 = 720.00.

Ending member deductible = 1,500.00 (satisfied — 1,500.00 credited toward the 1,500.00 individual threshold).

Check OOPM: member OOP was restarted at zero. 1,680.00 < 6,000.00 individual OOPM, so no OOPM cap applies. Family OOPM 12,000.00 — no indication of family totals; assume zero other. Fine.

Required keys:
- "deductible_applied": 1500.00
- "coinsurance_amount": 180.00
- "member_responsibility": 1680.00
- "plan_paid": 720.00
- "ending_member_deductible": 1500.00

All numbers with two decimals as plain numbers.

The key subtlety: the mid-year change provision says accumulators do NOT carry forward, so the prior 1,500 deductible credit is wiped out, and the member must meet the deductible again. The trap is to think the deductible is already satisfied.

Ending member deductible: the running year-to-date total of deductible credits — but post-restart, the member's deductible balance/accumulator is 1,500.00 after this claim (credited under the new design). So ending_member_deductible = 1500.00.

Output JSON with exactly these keys.