Aggregate HDHP, five members, twenty-two claims
Generated from a seeded stream (seed 1109) and adjudicated by the Parity ledger engine (src/tasks/ledger-engine.ts) over 25 lines and 5 members. The family deductible is met, unwound below the line by a void, and met again by a different member.
Field mean
69.0
across 28 models
Models scoring 100
16
of 28
Models scoring 0
5
of 28
What the model was given
PLAN DOCUMENT — Trinity HDHP 3200 (synthetic)
Plan year: 2026-01-01 through 2026-12-31. All amounts are per plan year.
Deductible
Individual (in-network) ................ 3200.00
Family (in-network) .................... 6400.00
Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure.
Out-of-network (individual) ............ 6400.00
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) ................ 7000.00
Family (in-network) .................... 14000.00
Individual (out-of-network) ............ 14000.00
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 ......... 10% member / 90% plan
Coinsurance after deductible, out-of-network ..... 40% member / 60% plan
This plan has no copays. Every covered service, including office visits,
emergency care, and retail pharmacy, is subject to the deductible and then
coinsurance.
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.
CLAIM ADJUSTMENTS AND VOIDS (addendum to the plan document)
Claims are adjudicated in the order they appear on the ledger, which is the
order the plan received them.
ADJUSTMENT. When a line is an adjustment to an earlier claim, the credits that
claim generated — its deductible credit and its member responsibility — are
removed from every accumulator they touched (the member's and the family's),
and the claim is adjudicated again at its corrected values against the
accumulators AS THEY STAND at the point the adjustment is processed. Claims
processed between the original and the adjustment are NOT reprocessed; their
results stand as first adjudicated.
VOID. When a line voids an earlier claim, its credits are removed in the same
way and nothing replaces them. A voided claim has no member responsibility
and no plan payment.
An adjustment or void affects only the claim it names.
ACCUMULATORS (addendum to the plan document)
A claim's deductible_applied is the LESSER of its allowed amount and the room
left under the deductible threshold that applies to it:
in-network ......... the smaller of the member's individual remainder and
the family remainder (embedded), or the family
remainder alone (aggregate);
out-of-network ..... the out-of-network individual remainder, measured
against the member's same single deductible balance.
Once the applicable threshold is met, deductible_applied is 0.00, including
for a copay that would otherwise credit the deductible.
A balance is the running total of deductible_applied (for a deductible) or
of member_responsibility (for an out-of-pocket balance). Because the
out-of-network thresholds are higher, out-of-network claims can carry a
member's balance past the in-network individual amount, and the family
balances past the family amounts; the balances are not capped at the
in-network amounts.
Out-of-network claims are measured against the out-of-network individual
thresholds only; the family amounts, which are in-network amounts, do not
limit an out-of-network claim. The credits an out-of-network claim generates
still accumulate to the member's balance and to the family balance.FAMILY ACCUMULATORS as of the moment before Line 1
A (subscriber) deductible 0.00 out-of-pocket 0.00
B (spouse) deductible 0.00 out-of-pocket 0.00
C (child) deductible 0.00 out-of-pocket 0.00
D (child) deductible 0.00 out-of-pocket 0.00
E (child) deductible 0.00 out-of-pocket 0.00
Family total deductible 0.00 out-of-pocket 0.00
LEDGER (process in the order listed; every line updates the accumulators the next is measured against)
Line 1 — Claim 1 — 2026-01-07 — A (subscriber)
Service ......... Generic retail pharmacy fill, in-network
Network ......... In-network
Billed charge ... 138.51
Allowed amount .. 74.87
Line 2 — Claim 2 — 2026-01-17 — C (child)
Service ......... Inpatient admission, out-of-network
Network ......... Out-of-network
Billed charge ... 20135.31
Allowed amount .. 10883.95
Line 3 — Claim 3 — 2026-02-01 — C (child)
Service ......... Diagnostic laboratory panel, out-of-network
Network ......... Out-of-network
Billed charge ... 1790.78
Allowed amount .. 967.99
Line 4 — Claim 4 — 2026-02-15 — A (subscriber)
Service ......... Urgent care visit, in-network
Network ......... In-network
Billed charge ... 472.38
Allowed amount .. 255.34
Line 5 — Claim 5 — 2026-03-01 — A (subscriber)
Service ......... Emergency department visit, in-network
Network ......... In-network
Billed charge ... 6558.58
Allowed amount .. 3545.18
Line 6 — Claim 6 — 2026-03-07 — A (subscriber)
Service ......... Allergy testing, in-network
Network ......... In-network
Billed charge ... 1687.00
Allowed amount .. 911.89
Line 7 — Claim 7 — 2026-03-19 — B (spouse)
Service ......... Ambulatory surgery, in-network
Network ......... In-network
Billed charge ... 14514.18
Allowed amount .. 7845.50
Line 8 — Claim 8 — 2026-03-28 — D (child)
Service ......... Ambulatory surgery, in-network
Network ......... In-network
Billed charge ... 12488.67
Allowed amount .. 6750.63
Line 9 — Claim 9 — 2026-04-11 — B (spouse)
Service ......... Inpatient admission, in-network
Network ......... In-network
Billed charge ... 22663.00
Allowed amount .. 12250.27
Line 10 — Claim 10 — 2026-04-27 — D (child)
Service ......... Inpatient admission, in-network
Network ......... In-network
Billed charge ... 22615.34
Allowed amount .. 12224.51
Line 11 — Claim 11 — 2026-05-10 — D (child)
Service ......... Annual wellness visit, out-of-network
Network ......... Out-of-network
Billed charge ... 1229.55
Allowed amount .. 664.62
Line 12 — Claim 12 — 2026-05-17 — B (spouse)
Service ......... Generic retail pharmacy fill, out-of-network
Network ......... Out-of-network
Billed charge ... 55.85
Allowed amount .. 30.19
Line 13 — Claim 13 — 2026-05-24 — D (child)
Service ......... Screening colonoscopy, no polyp removed, out-of-network
Network ......... Out-of-network
Billed charge ... 1325.54
Allowed amount .. 716.51
Line 14 — VOID of Claim 3 — 2026-06-06 — C (child)
Reason .......... Duplicate submission of a claim already paid.
Line 15 — Claim 15 — 2026-06-18 — A (subscriber)
Service ......... Outpatient endoscopy, out-of-network
Network ......... Out-of-network
Billed charge ... 4312.81
Allowed amount .. 2331.25
Line 16 — VOID of Claim 6 — 2026-06-22 — A (subscriber)
Reason .......... Duplicate submission of a claim already paid.
Line 17 — Claim 17 — 2026-06-26 — E (child)
Service ......... Physical therapy course, out-of-network
Network ......... Out-of-network
Billed charge ... 2541.33
Allowed amount .. 1373.69
Line 18 — Claim 18 — 2026-07-10 — C (child)
Service ......... Diagnostic laboratory panel, out-of-network
Network ......... Out-of-network
Billed charge ... 1097.44
Allowed amount .. 593.21
Line 19 — Claim 19 — 2026-07-23 — B (spouse)
Service ......... Urgent care visit, in-network
Network ......... In-network
Billed charge ... 407.85
Allowed amount .. 220.46
Line 20 — Claim 20 — 2026-08-03 — A (subscriber)
Service ......... Routine immunisation, in-network
Network ......... In-network
Billed charge ... 2299.77
Allowed amount .. 1243.12
Line 21 — Claim 21 — 2026-08-17 — C (child)
Service ......... Emergency department visit, in-network
Network ......... In-network
Billed charge ... 6505.14
Allowed amount .. 3516.29
Line 22 — Claim 22 — 2026-08-23 — E (child)
Service ......... Inpatient admission, in-network
Network ......... In-network
Billed charge ... 23078.79
Allowed amount .. 12475.02
Line 23 — ADJUSTMENT to Claim 20 — 2026-09-08 — A (subscriber)
Reason .......... Provider appeal: allowed amount corrected downward after contract rate review.
Billed charge ... 2299.77
Allowed amount .. corrected to 745.87
Line 24 — Claim 24 — 2026-09-20 — D (child)
Service ......... Primary care office visit, in-network
Network ......... In-network
Billed charge ... 372.26
Allowed amount .. 201.22
Line 25 — Claim 25 — 2026-09-28 — D (child)
Service ......... Physical therapy course, in-network
Network ......... In-network
Billed charge ... 2790.45
Allowed amount .. 1508.35
Report the FINAL components on the books for Claims 19, 20, 25 — for a claim that was adjusted, the components as re-adjudicated by the adjustment — and the ending accumulators for every member and for the family.
Required keys for this item:
claim_19_member_responsibility, claim_19_plan_paid, claim_19_deductible_applied, claim_19_copay_amount, claim_19_coinsurance_amount
claim_20_member_responsibility, claim_20_plan_paid, claim_20_deductible_applied, claim_20_copay_amount, claim_20_coinsurance_amount
claim_25_member_responsibility, claim_25_plan_paid, claim_25_deductible_applied, claim_25_copay_amount, claim_25_coinsurance_amount
ending_deductible_a, ending_oopm_a (for A (subscriber))
ending_deductible_b, ending_oopm_b (for B (spouse))
ending_deductible_c, ending_oopm_c (for C (child))
ending_deductible_d, ending_oopm_d (for D (child))
ending_deductible_e, ending_oopm_e (for E (child))
ending_family_deductible, ending_family_oopmjson{
"kind": "fields",
"tolerance": 0.011,
"fields": {
"claim_19_member_responsibility": 0,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0,
"claim_19_copay_amount": 0,
"claim_19_coinsurance_amount": 0,
"claim_20_member_responsibility": 0,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0,
"claim_20_copay_amount": 0,
"claim_20_coinsurance_amount": 0,
"claim_25_member_responsibility": 0,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0,
"claim_25_copay_amount": 0,
"claim_25_coinsurance_amount": 0,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
}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 · Anthropic40.9s · 3,847 out | 42.0s · 3,865 out | 51.6s · 4,319 out
Reasoning · 3,322 tokens
[omitted]json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 3,340 tokens
[omitted]json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 3,794 tokens
[omitted]json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Gemini 3.7 Flash · Google51.6s · 7,966 out | 82.8s · 11,830 out | 50.1s · 7,344 out
Reasoning · 7,436 tokens
**Analyzing HDHP Plan**
I'm currently dissecting the Trinity HDHP 3200 plan details. My focus is on understanding the deductible structure, specifically how individual and family in-network deductibles interact with out-of-network costs, and how all credits contribute to a unified member deductible balance.
**Clarifying Deductible Mechanics**
I'm delving into the intricacies of the aggregate HDHP structure. Specifically, I'm trying to pinpoint how individual and family deductibles converge under the aggregate model, and how that impacts the application of coinsurance, especially in relation to the out-of-pocket maximums.
**Processing First Claim**
I am now processing the first claim, a generic pharmacy fill incurred in-network by member A. My current focus is on how this initial expense affects individual and family deductibles and out-of-pocket maximums, ensuring accurate ledger updates.
**Applying Out-of-Network Costs**
I've processed an out-of-network inpatient admission for member C. The deductible was met, and coinsurance is now being applied. This is impacting the family deductible and out-of-pocket maximums, moving closer to the aggregate thresholds.
**Updating Deductible Calculations**
I've processed another set of in-network claims for member A. I'm now updating both individual and family deductibles and out-of-pocket maximums, ensuring the correct application of coinsurance after the family deductible has been met.
**Calculating Coinsurance Accurately**
I'm now processing new in-network claims for ambulatory surgery and an inpatient admission. My current focus is on accurately calculating the coinsurance amounts and ensuring these impact the family out-of-pocket maximums correctly, while also observing how individual member limits are affected.
**Applying Out-of-Network Costs**
I'm now analyzing an out-of-network wellness visit for member D. It appears this service is subject to the out-of-network deductible, and I'm calculating how much of the allowed amount applies to that.
**Processing Out-of-Network Services**
I'm now analyzing out-of-network claims, focusing on how both a wellness visit and a pharmacy fill impact member D's individual deductible and out-of-pocket maximums, and also how they contribute to the overall family balances. This includes accounting for the specific out-of-network deductible rules.
**Adjusting Balances with Claims**
I'm now adjusting individual and family deductible and out-of-pocket balances based on new out-of-network claims and voided prior claims, ensuring accurate ledger updates after processing these changes.
**Processing Out-of-Network Claims**
I'm currently analyzing new out-of-network physical therapy and lab claims for members E and C. I am applying the out-of-network deductible and coinsurance rules, updating individual and family deductibles and out-of-pocket maximums accordingly.
**Updating In-Network Deductible**
I am now processing an in-network urgent care visit for member B, and I'm evaluating how this claim impacts the family deductible.
**Confirming Family OOPM Limit**
I'm confirming the family in-network out-of-pocket maximum. It appears the family OOPM has been met and fully satisfied, meaning subsequent in-network claims are paid at 100% of the allowed amount.
**Paying Preventive Claims**
I've confirmed that in-network preventive services are paid at 100% and do not affect any accumulators. I am now processing an in-network emergency department visit for member C, and verifying its impact given that the family deductible and out-of-pocket maximum have already been met.
**Verifying Final Balances**
I'm now re-evaluating all processed claims, including adjustments and new in-network services. My focus is on confirming each member's and the family's final deductible and out-of-pocket balances, ensuring all credits and payments are correctly accounted for.
**Reconciling Claim Totals**
I am now recalculating individual and family deductible and out-of-pocket balances after accounting for claim voids, out-of-network services, and in-network preventive care. My focus is on ensuring accuracy across all member accounts and the aggregate family totals, particularly in light of the met family OOPM.
json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 11,299 tokens
**Analyzing Ledger Rules**
I'm currently dissecting the ledger's rules with a focus on the Trinity HDHP 3200 plan. My immediate concern is understanding how the individual deductible of $3200.00 interacts with the aggregate structure, specifically regarding the coinsurance threshold.
**Clarifying Deductible Interactions**
I'm now focusing on the aggregate plan's behavior. Specifically, I'm noting that coinsurance isn't applied until the family deductible is met, irrespective of individual contributions. I'm also tracking how in-network and out-of-network credits converge on a single member deductible balance.
**Investigating OOPM Application**
I'm now scrutinizing the out-of-pocket maximum rules, specifically their interplay with aggregate versus embedded structures and in-network versus out-of-network coverage. I'm verifying if the individual in-network OOPM of $7000 caps a member's costs even before the family maximum of $14000 is reached.
**Tracing Claim Components**
I'm now meticulously tracing each claim component against the accumulated balances. My current focus is on applying the in-network coinsurance of 10% to the allowed amount after deductible, and I'm noting that preventive services, whether in or out-of-network, have distinct cost-sharing rules.
**Applying OON Deductible**
I'm processing an out-of-network inpatient claim now. I've applied the individual deductible, leaving a remainder. I'm calculating the member's coinsurance responsibility and checking it against their individual out-of-pocket maximum.
**Calculating Claim Costs**
I am now processing an out-of-network diagnostic lab claim for C. Since their OON deductible is met, I've calculated the 40% member coinsurance. I've also begun an in-network urgent care claim for A, noting the family deductible is now fully satisfied and applying the 10% INN coinsurance.
**Updating Accumulators**
I'm now updating the accumulators based on A's in-network emergency department visit and allergy testing claims. The family deductible is met, so I'm applying 10% coinsurance to both, carefully tracking member and family out-of-pocket balances.
**Updating Accumulators**
I am now processing an in-network ambulatory surgery claim for B. Since the family deductible is met, I've applied the 10% coinsurance and updated B's individual and the family's out-of-pocket balances. Concurrently, I am processing an identical claim for D, applying the same logic.
**Updating Claim Accumulators**
I'm now processing an in-network inpatient admission for B, applying coinsurance after the family deductible was met, and updating individual and family OOP balances. Concurrently, I'm handling an identical claim for D, applying the same logic to its accumulators.
**Applying OON Rules**
I am now applying the out-of-network rules to D's annual wellness visit. The full allowed amount is applied to their individual OON deductible. I'm clarifying that OON claims count towards individual OON limits and family accumulators, but not the family INN OOPM.
**Processing OON Pharmacy & Colonoscopy**
I'm processing an OON pharmacy claim, applying the allowed amount to the deductible and updating balances. Next, I'm handling an OON colonoscopy, noting it counts towards the individual OON deductible, and then updating all relevant accumulators, including family totals.
**Updating OON Accumulators**
I'm now processing an out-of-network pharmacy claim and a colonoscopy. I'm applying the allowed amounts to the deductible and updating all relevant balances, including individual and family totals. The voiding of Claim 6 is also being factored into A's accumulators.
**Continuing OON Deductible Application**
I'm now applying an out-of-network deductible to a diagnostic lab claim, calculating the coinsurance and updating individual and family OOP balances accordingly. This process continues as I confirm the family deductible has been satisfied for an in-network urgent care claim.
**Revising OOPM Logic**
I'm revisiting the out-of-pocket maximum calculations. It appears my prior logic incorrectly allowed the family OOP to exceed the defined maximum. I am now refining the application of coinsurance and deductible applied amounts to ensure they properly cap at the individual and family OOPM limits.
**Adjusting OOPM Calculations**
I'm refining the out-of-pocket maximum logic. OON balances do not cap at INN amounts; they apply to their own higher thresholds, though still contributing to family totals. The family OOPM is fully satisfied, impacting subsequent INN claim responsibilities.
**Finalizing OOPM Logic**
I'm now confirming that the family out-of-pocket maximum has been satisfied. This means all subsequent in-network claim costs will be covered by the plan, significantly simplifying remaining calculations.
**Verifying Final Accumulators**
I'm now cross-referencing the settled claims against the final accumulator states. It appears the family OOPM was satisfied prior to these last few in-network claims, meaning they should be fully covered by the plan. I'm confirming this outcome and verifying no further member responsibility.
**Confirming Final Coverage**
I am now confirming that the family out-of-pocket maximum has indeed been satisfied. This means all subsequent in-network claim costs are fully covered by the plan, simplifying the remaining calculations significantly. I am verifying this outcome.
**Reviewing Final Claim Calculations**
I am now reviewing the final few in-network claim calculations, specifically for B and D. The family out-of-pocket maximum having been satisfied simplifies these by ensuring the plan covers all subsequent costs after deductible application, which in this case is zero. I am confirming the accuracy of these zero-cost member responsibilities.
**Revising OON Deductible Application**
I'm re-evaluating how the out-of-network deductible applies to D's claims. I've identified that after applying the full allowed amount to the OON deductible, there is no remaining balance for coinsurance. This correct application is now updating both individual and family accumulators.
**Adjusting Member Responsibilities**
I am now correcting accumulator values based on new claim data. I'm removing the previously calculated member responsibility for claim 6 from both C and the family's balances, and then recalculating C's OOPM and deductible with claim 18.
**Verifying Member Balances**
I'm now verifying that the sum of individual deductibles matches the family deductible and that the sum of individual out-of-pocket costs aligns with the family OOPM, ensuring all accumulator calculations are consistent and accurate.
json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.13",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 6,814 tokens
**Confirming Plan Details**
I'm confirming the specifics of the Trinity HDHP 3200 plan. My focus is on understanding the deductible structure, particularly the aggregate family deductible, which is set at $6400, as opposed to an individual one.
**Analyzing Deductible Mechanics**
I'm now digging into how the aggregate deductible works. It seems all in-network and out-of-network costs contribute to a single family balance before coinsurance kicks in. Out-of-network claims have a peculiar restriction; they only count towards individual out-of-network thresholds, not the family amounts.
**Calculating Individual Exposure**
I'm now calculating the remainder for the family deductible and then focusing on individual out-of-network exposure. It appears individual out-of-network claims are capped by the individual out-of-pocket maximum, not the family one.
**Calculating Member Responsibility**
I'm now calculating the exact member responsibility for the latest claims. This involves factoring in remaining deductibles, coinsurance, and ensuring we don't exceed out-of-pocket maximums for both individual and family scenarios, including specific out-of-network considerations.
**Calculating Member Responsibility**
I've now calculated the specific member responsibilities for the latest claims. This involves applying the remaining deductible and coinsurance for each, ensuring individual and family out-of-pocket maximums are respected, and accounting for the unique out-of-network rules.
**Calculating Member Responsibility**
I've finalized the member responsibility calculations for recent claims. I applied the remaining deductibles and coinsurance, while ensuring both individual and family out-of-pocket maximums are adhered to, specifically considering the unique out-of-network clauses.
**Applying Deductible to Claims**
I'm processing two recent claims. For Claim 10 (Inpatient, child), I've applied 10% coinsurance, totaling $1222.45, and updated individual and family deductibles. For Claim 11 (Wellness, child, OON), the full $664.62 applied to the child's OON deductible due to a specific note.
**Updating Deductible Calculations**
I've finalized the member responsibility for two new claims. For the first, I applied the remaining deductible and coinsurance. The second required the full amount to go towards the child's out-of-network deductible. I'm now unwinding a previously processed claim.
**Revising Calculations**
I'm now unwinding a previous claim and processing new ones. This involves adjusting deductible and out-of-pocket figures, including specific calculations for out-of-network services and applying a void. The latest out-of-network claim is being assessed against remaining individual limits.
**Adjusting OPM Calculations**
I'm reassessing the in-network out-of-pocket maximum for Claim 19. It seems that once the family OOPM is met, the plan covers 100% of in-network costs, reducing member responsibility to zero for this claim.
**Refining OPM Limits**
I've discovered Claim 19 was incorrectly processed. It’s a preventive service, meaning no cost-sharing or accumulator movement. I'm adjusting its impact and re-evaluating Claim 20, a routine immunization, as it should also have zero cost share and not affect accumulators.
**Processing Preventive Claims**
I am now confirming that preventive services do not impact accumulators. Claims 20, 22, and 24, all in-network and preventive in nature, generated zero cost-sharing and did not move any deductibles or out-of-pocket maximums.
**Validating Accumulated Values**
I'm now verifying all accumulator values post-claim processing. I've confirmed the family deductible and OOPM have been met for the latest claim, resulting in zero member responsibility and full plan payment. My next step is a detailed check of individual and family accumulator sums.
json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100GPT-5.5 · OpenAI51.0s · 4,268 out | 53.5s · 4,424 out | 54.7s · 4,963 out
Reasoning · 3,869 tokens
**Clarifying OOP Mechanics**
I’m brainstorming how components of out-of-pocket (OOP) costs work with regard to deductibles and coinsurance. If a member hits their mid-claim deductible, the deductible continues to apply until they reach the threshold. I wonder if coinsurance is related to the minimum cost share left? I need to clarify that once a member reaches OOP maximum, they might be capped on costs. I’m needing to verify these calculations and how they interact with deductible credits.
**Clarifying vaccination terms**
I’m looking at routine immunization and whether it’s considered preventive care that requires no cost share. It seems like the answer is yes. I think the idea is that preventive services, which include immunizations, typically don’t come with out-of-pocket expenses, making it accessible for families, which is really important. I have to keep in mind the context and details to ensure I'm on point here.
**Finalizing deductible balances**
I need to compile the final balances for deducted claims in a clear table format, listing each item with its corresponding values. I’ll check the claims after a family out-of-pocket cap is reached to see if the zero member responsibilities affect the deductible. It seems like once a member hits the out-of-pocket maximum, the plan should cover 100%. I'm just making sure everything is clear and accurate, especially regarding the deductible and claims statuses.
**Calculating final deductibles**
So, for E in-network, there’s no deductible since the family deductible is satisfied due to out-of-network credits. For member A, I’ll calculate two claims that total up to 2406.12. Claim 6 is voided and claim 20 has nothing. Member B has only a small deductible from claim 12. As for C, I’ll include a bigger claim amount but adjust for voids. Member D’s total comes from two claims. I finally sum everything for the family deductible, which totals 11591.13, matching the expected total.json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 4,025 tokens
**Calculating ledger adjustments**
I need to carefully calculate the ledger, making adjustments for any voids. The in-network family deductible is $6,400, with no individual limits. For out-of-network (OON), the individual deductible is also $6,400. The OON coinsurance is 40% after the member deductible. The out-of-pocket (OOP) maximum for the individual OON is $14,000, whereas it's $7,000 for in-network. I need to determine how the OOP applies across networks, especially since out-of-network thresholds are higher.
**Clarifying deductibles and OOP balances**
I need to clarify what applies to deductibles and out-of-pocket (OOP) balances. Since out-of-network (OON) claims can exceed in-network amounts, this affects member balances. OON claims are measured against individual thresholds, not family amounts. For OOP maximums (OOPM), I should ensure member responsibilities don’t exceed these limits. Once a member reaches the OOP maximum, the plan covers 100%. For preventive services, in-network care has no cost share, and there's no accumulation for these.
**Evaluating preventive services and deductibles**
It looks like Claim20 for routine immunizations in-network is likely covered with no cost share for both original and adjusted claims. For out-of-network (OON) preventive services like colonoscopies, these would be subject to OON deductibles and coinsurance. I need to simulate the processing using stored per-claim components, checking if the family deductibles accumulate credits from both in-network and OON claims. For a family deductible threshold of $6,400, if it reaches that amount, the deductible applied would be zero, but balances can exceed $6,400 from OON claims.
**Analyzing cost shares and deductibles**
I'm trying to understand how out-of-pocket (OOP) caps and member cost shares work. If the OOP cap means the member's share can't exceed a certain amount, does that mean the deductible credit equals the cost share amount? It looks complex, especially with how deductibles are applied and whether they can exceed the member's responsibility. I'm reviewing specific claim lines to clarify what the plan covers, especially for pharmacy and inpatient scenarios. It seems I need to confirm how the OOP cap interacts with these specifics.json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 4,564 tokens
**Exploring cost-sharing mechanisms**
I’m thinking about how cost sharing for covered non-preventive services works. First, I consider the out-of-pocket maximum, which might limit the member's responsibility. The deductible is applied first, and it’s the lesser of either the allowed amount or the deductible room, determined per network threshold. After that, there’s coinsurance on any remaining amount—provided that the threshold has been met. It’s a bit complex, but I want to make sure I understand it correctly!
**Evaluating OON balance and JSON formatting**
I'm considering the situation where the balance has exceeded 7000 due to OON credits. I think member C would be covered even without family involvement. However, a potential issue arises: once member C's OOP balance exceeds 7000, it seems the line for OON might be measured against OON OOPM of 14000 instead of 7000.
I’m also pondering if I need to output all dollar strings in JSON format, since that could mean using strings to maintain two decimal places. So, whether values like "123.45" can preserve formatting is something I have to figure out.
**Considering JSON formatting for dollar amounts**
I’m weighing how to handle dollar amounts in JSON formatting. While many use a numeric format like 1234.50, it seems there's a risk of confusion during parsing—especially since 0.00 might be treated as just 0 in some languages.
To be safe, I think it makes sense to represent dollar amounts as strings like "123.45" to ensure they maintain two decimal places. The task also specifies to report every dollar amount as a plain number without currency symbols. Rounding based on typical rules should also be considered for accurate representation.
**Recomputing rounded amounts**
I need to round the amounts down, so for example, 25.534 becomes 25.53. The other amounts include line 5 at 354.52, line 6 at 91.19, line 8 at 675.06, line 9 at 1225.03, line 10 at 1222.45, and line 18 at 237.28. I’ll sum the family OOP along with the rounded member responses.
It looks like I’ll need to use the final line-level amounts, ensuring they’re rounded correctly. I should create a ledger table for the final postings as well.
**Clarifying out-of-network claims**
Out-of-network thresholds are higher, meaning that claims can exceed in-network account limits. Individual balances can surpass in-network amounts, similarly affecting family balances. Out-of-network claims are assessed solely against those individual thresholds. There's a note about an ACCUMULATORS addendum after "deductible_applied," emphasizing that the rules don't apply to family amounts when it comes to out-of-network claims. I wonder if this might impact out-of-pocket costs too, considering the plural thresholds and how family amounts factor in.json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100GPT-5.6 Sol · OpenAI33.6s · 2,453 out | 26.0s · 2,046 out | 30.5s · 2,351 out
json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 1,647 tokens
**Calculating thresholds and claims**
I need to be precise here. I think I should consider the OOP model for individual and network-specific thresholds. For example, in-network has a threshold of 7,000, while OON has 14,000. The family OOP for in-network is 14,000, and this affects claims. I'll also have to track credits and adjustments carefully. Preventive claims are zero-cost shares in-network, and I'll ensure to round costs to the nearest cent for accuracy. It seems like there's a lot to manage!
**Calculating deductibles and coinsurance**
I need to accurately calculate deductibles down to the exact cent. I'll round coin percentages up to the nearest half. Tracking things is crucial here. For in-network, the family has a remaining deductible of 6,400, and for OON, it's a bit more complex. I see that the coinsurance is also relevant as I review the remaining amounts. I need to ensure that I’m adjusting these appropriately, especially as the family threshold is exceeded. It's like being meticulous with numbers!json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 1,952 tokens
**Considering JSON output formats**
I’m thinking about how to use values as strings for JSON output. It seems the prior harness expects them this way, especially since they involve two decimal places. It’s likely they prefer outputs formatted like "0.00". The contract mentions reporting dollar amounts as plain numbers with two decimals, so I might need to use strings for amounts like $1234.50. I remember previous tasks dealt with strings a lot, so sticking with that might be wise.
**Verifying OOP calculations**
I'm checking the calculations for the Out-of-Pocket (OOP) maximum. For section A, I’ve added the amounts: 74.87 + 25.53 + 354.52, which totals 454.92, and then in claim6 (91.19 removed) + claim15 (2331.25) equals 2786.17. For section C, claim2 is 8193.58, and line18 (237.28) gives a total of 8430.86. In section D, I sum 675.06 + 1222.45 + 664.62 + 716.51, resulting in 3278.64. I’ll ensure it’s all formatted in JSON.json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Grok 4.6 · xAI101.7s · 8,871 out | 101.3s · 9,059 out | 80.1s · 7,204 out
Reasoning · 8,442 tokens
The user wants me to process a plan-year ledger for Trinity HDHP 3200 and report specific claim components and ending accumulators.
I need to process this ledger carefully, tracking each claim's impact on the accumulators. Let me start by noting the plan details:
- **Trinity HDHP 3200**
- Aggregate deductible: Family IN 6400, OON 6400
- Individual IN OOPM: 7000, Family 14000
- Individual OON OOPM: 14000
- Coinsurance: IN 10%/90%, OON 40%/60%
- No copays
Let me process each claim in order:
**Line 1 - Claim 1 (A, 2026-01-07)**
- IN pharmacy, allowed 74.87
- Family remainder: 6400
- Deductible applied: 74.87
- Member responsibility: 74.87 * 10% = 7.49
- Plan paid: 67.38
**Line 2 - Claim 2 (C, 2026-01-17)**
- OON inpatient, allowed 10883.95
- C's OON ded balance: 0
- Deductible applied: 6400
- Remaining allowed: 4483.95
- 40% coinsurance: 1793.58
- Member responsibility: 8193.58
- Plan paid: 2690.37
**Line 3 - Claim 3 (C, 2026-02-01)**
- OON lab, allowed 967.99
- C's OON ded balance: 6400
- Deductible applied: 0
- 40% coinsurance: 387.20
- Member responsibility: 387.20
- Plan paid: 580.79
**Line 4 - Claim 4 ( 2026-02-15)**
- IN urgent care, allowed 255.34
- Family ded met
- 10% coinsurance: 25.53
- Member responsibility: 25.53
- Plan paid: 229.81
**Line 5 - Claim 5 (A, 2026-03-01)**
- IN ED, allowed 3545.18
- Family ded met
- 10% coinsurance: 354.52
- Member responsibility: 354.52
- Plan paid: 3190.66
**Line 6 - Claim 6 (A, 2026-03-07)**
- IN allergy, allowed 911.89
- Family ded met
- 10% coinsurance: 91.19
- Member responsibility: 91.19
- Plan paid: 820.70
**Line 7 - Claim 7 (B, 2026-03-19)**
- IN ambulatory surgery, allowed 7845.50
- Family ded met
- 10% coinsurance: 784.55
- Member responsibility: 784.55 (B's individual OOPM 7000)
- Plan paid: 7060.95
**Line 8 - Claim 8 (D, 2026-03-28)**
- IN ambulatory surgery, allowed 6750.63
- Family ded met
- 10% 675.06
- Member responsibility: 675.06
- Plan paid: 6075.57
**Line 9 - Claim 9 (B, 2026-04-11)**
- IN inpatient, allowed 12250.27
- Family ded met
- 10% 1225.03
- Member responsibility: 1225.03 (within OOPM)
- Plan paid: 11025.24
**Line 10 - Claim 10 (D, 2026-04-27)**
- IN inpatient, allowed 12224.51 10% 1222.45
- Member responsibility: 1222.45
- Plan paid: 11002.06
**Line 11 - Claim 11 (D, 2026-05-10)**
- OON wellness, allowed 664.62
- D 0 ded balance
- Deductible applied: 664.62
- Member responsibility: 664.62
- Plan paid: 0
- Plan pays 100% after OOPM reached
**Line 12 - Claim 12 (B, 2026-05-17 30.19)**
- OON pharmacy
- Deductible applied: 30.19
- Member responsibility: 30.19
- Plan paid: 0
**Line 13 - Claim 13 (D, 2026-05-24 716.51)**
- OON colonoscopy
- Deductible applied: 716.51
- Member responsibility: 716.51
- Plan paid: 0
**Line 14 - VOID Claim 3**
- Removing 387.20 from C and family OOPM
**Line 15 - Claim 15 (A, 2026-06-18 2331.25)**
- OON endoscopy
- Deductible applied: 2331.25
- Member responsibility: 2331.json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 8,630 tokens
The user wants me to process a complex health plan ledger and report specific claims and ending accumulators.
claim_19_member_responsibility: 220.46
claim_19_plan_paid: 220.46
claim_19_deductible_applied: 0.00
claim_19_copay_amount: 0.00
claim_19_coinsurance_amount: 0.00
claim 19 is an in-network urgent care visit.
Family deductible is already met (6400), so deductible_applied = 0.
Allowed amount 220.46 is paid 100 % by plan (no coinsurance yet).
Member responsibility = 0.00 (plan paid full allowed).
claim_ 20_member_responsibility: 1243.12
claim_20_plan_paid: 1243.12
claim_20_deductible_applied: 0.00
claim_20_copay_amount: 0.00
claim_20_coinsurance_amount: 0.00
claim 20 is a routine immunisation (preventive in-network).
Preventive services are 100 % plan-paid with no cost-share or accumulator impact.
Member responsibility = 0.00 (plan paid full allowed).
claim_25_member_responsibility: 1508.35
claim_25_plan_paid 1508.35
claim_25_deductible_applied: 0.00
claim_25_copay_amount: 0.00
claim_25_coinsurance_amount: 0.00
claim 25 is an in-network physical therapy course.
Family deductible is met, so deductible_ap 0.
Allowed amount 1508.35 is paid 100 % by plan (no coinsurance yet).
Member responsibility = 0.00 (plan paid full allowed).
ending_deductible_a: 74.87
ending_oopm_a: 454.92
ending_deductible b: 30.19
ending_oopm_b: 2039.77
ending_deductible_c: 6400.00
ending_oopm_c: 8580.78
ending_deductible_d: 664.62
ending_oopm_d: 2562. 13
ending_deductible_e: 0.00
ending_oopm_e: 0.00
ending_family_deductible: 7886.19
ending_family_oopm: 14058.10 (family OOPM reached; any future IN services would be 100 % plan-paid) <|tool_call_begin|> <parameter name="claim_19_member_responsibility">220.46</parameter> <parameter name="claim_19_plan_paid">220.46</parameter> <parameter name="claim_19_deductible_applied">0.00</parameter> <parameter name="claim_19_c opay_amount">0.00</parameter> <parameter name="claim_19_coinsurance_amount">0.00</parameter> <parameter name="claim_20_member_responsibility">1243.12</parameter> <parameter name="claim_20_plan_paid">1243.12</ parameter> <parameter name="claim_20_deductible_applied">0.00</parameter> <parameter name="claim_20_copay_amount">0.00</parameter> <parameter name="claim_20_coinsurance_amount">0.00</parameter> <parameter name=" claim_25_member_responsibility">1508.35</parameter> <parameter name="claim_25_plan_paid">1508.35</parameter> <parameter name="claim_25_deductible_applied">0.00</parameter> <parameter name="claim_25_copay _amount">0.00</parameter> <parameter name="claim_25_coinsurance_amount">0.00</parameter> <parameter name="ending_deductible_a">74.87</parameter> <parameter name="ending_oopm_a">454.json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 6,775 tokens
The user wants me to process a health plan ledger and report specific claim components and ending accumulators.
I need to process this ledger step by step, tracking each member's deductible and out-of-pocket maximum (OOPM) accumulators, as well as the specific components for claims 19, 20, and 25 (including the adjusted claim 20).
Let me start by noting the plan details:
- Family in deductible: $6,400
- Individual in deductible: $3,200 (but aggregate)
- Family OOPM: $14,000
- Individual OOPM: $7,000 (in-network), $14,000 (out-of-network)
- Coinsurance: 10% member / 90 plan (in-network), 40% member / 60% plan (out-of-network)
- No copays
- Preventive services: no cost share
I'll process each claim in order, updating the accumulators accordingly.
**Line 1 - Claim 1 (A, IN pharmacy)**
- Allowed: $ 74.87
- IN claim: deductible_applied = min(74.87, 6400 - 0) = 74.87
- Member responsibility = 74.87 (10% coinsurance)
- Plan paid = 0
- Updates: A_ded = 74.87, A_oop = 74.87
- Fam_ded = 74.87, Fam_oop = 74.87
**Line 2 - Claim 2 (C, OON inpatient)**
- Allowed: $10,883.95
- OON claim: deductible_applied = min 10,883.95, 6400 - 0 = 6400
- Remaining allowed = 4,483.95
- Member responsibility = 6400 + 0.4*4483.95 = 8193.58
- Plan paid = 0.6*4483. 95 = 2690.37
- Updates: C_ded = 6400, C_oop = 8193.58
- Fam_ded = 6474.87, Fam_oop = 8268.45
**Line 3 - Claim 3 (C, OON lab - VOID)**
- Voided, so no updates
**Line 4 - Claim 4 (A, IN urgent care)**
- Allowed: $255.34
- IN claim: deductible_applied = 0 (family deductible met)
- Member responsibility = 0.1*255.34 = 25.53
- Plan paid = 229.81
- Updates: A_oop = 100.40, Fam_oop = 8693.98
**Line 5 - Claim 5 (A, IN ED)**
- Allowed: $3,545.18
- IN claim: 0 deductible
- Member responsibility = 354.52
- Plan paid = 3190.66
- Updates: A_oop = 454.92, Fam_oop = 9048.50
**Line 6 - Claim 6 (A, IN allergy - VOID)**
- Voided 91.19 OOP
**Line 7 - Claim 7 (B, IN surgery)**
- Allowed: $7,845.50
- IN claim: 0 deductible
- Member responsibility = 784.55
- Plan paid = 7060.95
- Updates: B_oop = 784.55, Fam_oop = 9833.05
**Line 8 - Claim 8 (D, IN surgery)**
- Allowed: $6,750.63
- IN claim: 0 deductible
- Member responsibility = 675.06
- Plan paid = 6075. 57
- Updates: D_oop = 675.06, Fam_oop = 10508.11
**Line 9 - Claim 9 (B, IN inpatient)**
- Allowed: $12,250.27
- IN claim: 0 deductible
- Member responsibility = 1225 03
- Plan paid = 11025.24
- Updates: B_oop = 2009.58, Fam_oop = 11733.14
**Line 10 - Claim 10 (D, IN inpatient)**
- Allowed: $12,224.51
- IN claim: 0 deductible
- Member responsibility = 1222.45
- Plan paid = 11002.06
- Updates: D_oop = 1897.51, Fam_oop = 12955.59
**Line 11 - Claim 11 (D, OON wellness)**
- Allowed 664.62
- OON claim: deductible_applied = 664.62
- Member responsibility = 664.62
- Plan paid = 0
- Updates: D_ded = 664.62, D_oop = 2562.13, Fam_ded = 7139.json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Grok 4.5 · xAI154.3s · 10,571 out | 93.5s · 6,890 out | 114.6s · 7,897 out
Reasoning · 10,142 tokens
The problem is a complex health plan ledger calculation. I need to process all claims in order and track accumulators.
I’ll process the ledger line by line, applying each claim’s impact to the relevant member’s deductible balance, the family deductible, and the OOPM balances. I’ll track the remaining family deductible and each member’s remaining individual deductible (for OON claims). Preventive services (Lines 11 and 24) are $ 0 cost share.
Line 1 – Claim 1 (A, IN, pharmacy)
Family ded remaining: 6400
ded_applied = 74.87
plan_paid = 0
member_resp = 74.87
A_ded = 74.87
Fam_ded = 74.87
A_oop = 74.87
Fam_oop = 74.87
Line 2 – Claim 2 (C, OON, inpatient)
OON ded room = 6400 – 0 = 6400
ded_applied = 6400
remaining 4483.95
coins = 1793.58
member_resp = 8193.58
plan_paid = 2690.37
C_ded = 6400
Fam_ded = 6474.87
C_oop = 8193.58
Fam_oop = 8268.45
Line 3 – Claim 3 (C, OON, lab) – VOID (duplicate)
No change.
Line 4 – Claim 4 (A, IN, urgent care)
Fam ded remaining = 0
ded_applied = 0
coins = 25 .53
member_resp = 25.53
plan_paid = 229.81
A_oop = 100.40
Fam_oop = 8693.98
Line 5 – Claim 5 (A, IN, ED)
ded_applied = 0
coins = 354 .52
member_resp = 354.52
plan_paid = 3190.66
A_oop = 454.92
Fam_oop = 9048.50
Line 6 – Claim 6 (A, IN, allergy) – VOID (duplicate)
No change.
Line 7 – Claim 7 (B, IN, surgery)
ded_applied = 0
coins = 784.55
member_resp = 784.55
plan_paid = 7060.95
B_oop = 784.55
Fam_oop = 9833.05
Line 8 – Claim 8 (D, IN, surgery)
ded_applied = 0
coins = 675.06
member_resp = 675.06
plan_paid = 6075.57
D_oop = 675.06
Fam_oop = 10508.11 (still < 14000)
Line 9 – Claim 9 (B, IN, inpatient)
ded_applied = 0
coins = 1225.03
member_resp = 1225.03
plan_paid = 11025.24
B_oop = 2009.58 (still < 7000)
Fam_oop = 11733.14
Line 10 – Claim 10 (D, IN, inpatient)
ded_applied = 0
coins = 1222.45
member_resp = 1222.45
plan_paid = 11002. 06
D_oop = 1897.51 (still < 7000)
Fam_oop = 12955.59
Line 11 – Claim 11 (D, OON, wellness – preventive)
OON ded room = 6400 – 0 = 6400
ded 664.62
coins = 0 (preventive)
member_resp = 664.62
plan_paid = 0
D_ded = 664.62
Fam_ded = 7139.49
D_oop = 2562.13
Fam_oop = 13617. 72
Line 12 – Claim 12 (B, OON, pharmacy)
OON ded room = 6400 – 0 = 6400
ded 30.19
coins = 0
member_resp = 30.19
plan_paid = 0
B_ded = 30.19
Fam_ded = 7169.68
B_oop = 2039.77
Fam_oop = 13647.91
Line 13 – Claim 13 (D, OON, colonoscopy – preventive)
OON ded room = 6400 – 664 62 = 5735.38
ded 716.51
coins = 0
member_resp = 716.51
plan_paid = 0
D_ded = 1381.13
Fam_ded = 7886.19
D_oop = 3278.64
Fam 14464.42
Line 14 – VOID Claim 3
No change.
Line 15 – Claim 15 (A, OON, endoscopy)
OON ded room = 6400 – 74.87 = 6325.13
ded 2331.25
coins = 0 (preventive? No, diagnostic)
member_resp = 2331.25
plan_paid = 0
A_ded = 2406.12
Fam_ded = 10217.44
A_oop = 2877.36
Fam_oop = 16795.78
Line 16 – VOID Claim 6
No change.
Line 17 – Claim 17 (E, OON, PT)
OON ded room = 6400 – 0 = 6400
ded 1373.69
coins = 0
member_resp = 1373.69 (preventive? No)
plan_paid = 0
E_ded = 1373.69
Fam_ded = 11591.13
E_oop = 1373.69
Fam_oop = 18169.47
Line 18 – Claim 18 (C, O ON, lab)
OON ded room = 0
ded 0
coins = 237.28
member_resp = 237.28
plan_paid = 355.93
C_oop = 8430.86
Fam_oop = 18406.75
Line 19 – Claim 19 (B, IN, urgent care)
Fam ded remaining = 0
ded 0
coins = 22.05
member_resp = 22.05
plan_paid = 198.41
B_oop = 2061.82
Fam_oop = 18428.json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 6,461 tokens
The problem is a complex insurance claims ledger that I need to process carefully. I must track deductibles and out-of-pocket maximums for a family under an aggregate deductible structure.
I’ll process the ledger line by line, updating the running balances for each member and the family. I’ll track:
- Deductible applied (ded_applied)
- Member responsibility (member_responsibility)
- Plan paid (plan_paid)
- Deductible balance remaining (ded_bal)
– For IN claims: family_ded_bal = 6400 – Fam_ded
– For OON claims: oon_ind_ded_bal = 6400 – member_ded_bal
- OOP balance (oop_bal)
– IN claims: capped at 7000 per member / 140 00 per family
– OON claims: capped at 14000 per member (family OOPM does not apply)
All starting balances are zero.
**Line 1 – Claim 1 – A – IN – pharmacy – allowed 74.87**
IN aggregate ded: fam_ded_rem = 6400
ded_applied = 74.87
member_resp = 74.87 (10 % coinsurance not applicable)
plan_paid = 0
A_ded = 74.87
A_oop = 74.87
Fam_ded = 74.87
Fam_o op = 74.87
**Line 2 – Claim 2 – C – OON – inpatient – allowed 10883.95**
OON ded: oon_ind_rem = 6400
ded_applied = 6400
remaining = 4483.95
member_resp = 6400 + 0.4×4483.95 = 8193.58
plan_paid = 0.6×4483.95 = 2690.37
C_ded = 6400
C_oop = 8193.58
Fam_ded = 6474 .87
Fam_oop = 8268.45
**Line 3 – Claim 3 – C – OON – lab – allowed 967.99**
OON ded: rem = 0
ded_applied = 0
member_resp = 0.4×967.99 = 387.20
plan_paid = 580.79
C_oop = 8580.78
Fam_oop = 8655.65
**Line 4 – Claim 4 – A – IN – urgent care – allowed 255.34**
IN ded: fam_rem = 0
(family already met)
ded_applied = 0
member_resp = 0.1×255.34 = 25.53
plan_paid = 229.81
A_oop = 100.40
Fam_oop = 8681.18
**Line 5 – Claim 5 – A – IN – ED – allowed 3545.18**
ded_applied = 0
member_resp = 354.52
plan_paid = 3190.66
A_oop = 454.92
Fam_oop = 9035.70
**Line 6 – Claim 6 – A – IN – allergy – allowed 911.89**
ded_applied = 0
member_resp = 91.19
plan_paid = 820.70
A_oop = 546.11
Fam_oop = 9126.89
**Line 7 – Claim 7 – B – IN – amb surg – allowed 7845.50**
ded_applied = 0
member_resp = 784.55
plan_paid = 7060.95
B_oop = 784.55
Fam_oop = 9911.44
** Line 8 – Claim 8 – D – IN – amb surg – allowed 6750.63**
ded_applied = 0
member_resp = 675.06
plan_paid = 6075.57
D_oop = 675.06
Fam_oop = 10586.json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 7,468 tokens
The problem is a complex health plan ledger calculation. I need to process all claims in order and track accumulators.
I processed the ledger line by line, applying the Trinity HDHP 3200 rules exactly as described. Preventive services (immunization, wellness, allergy testing) were zero-cost-share. All in-network claims used the 10 % coinsurance after deductible. All out-of-network claims used the 40 % coinsurance after 6400 individual deductible. Once a member hit their individual OOPM (7000 in-network / 14000 out-of-network), the plan paid 100 % of any further allowed amount for that member. Family OOPM (14000) also capped the family total.
Here are the final components you asked for:
claim 19 (B, urgent-care, in-network)
claim_19_member_responsibility 220.46
claim_19_plan_paid 220.46
claim_19_deductible_applied 0.00
claim_19_copay_amount 0.00
claim_19_coinsurance_amount 220.46
claim 20 (A, routine immunization, in-network)
claim_20_member_responsibility 0.00
claim_20_plan_paid 1243.12
claim_20_deductible_applied 0.00
claim_20_copay_amount 0.00 (preventive)
claim_20_coinsurance_amount 0.00
claim 25 (D, physical therapy, in-network)
claim_25_member_responsibility 150.835
claim_25_plan_paid 1357.515
claim_25_deductible_applied 0.00 (family deductible already met)
claim_25_copay_amount 0.00
claim_25_coinsurance_amount 150.835
Ending accumulators (rounded to two decimals):
A (subscriber)
ending_deductible_a 74.87
ending_oopm_a 7000.00 (individual OOPM reached)
B (spouse)
ending_deductible_b 30.19
ending_oopm_b 7000.00 (individual OOPM reached)
C (child)
ending_deductible_c 6400.00
ending_oopm_c 8193. 58
D (child)
ending_deductible_d 1381.13
ending_oopm_d 7000.00 (individual OOPM reached)
E (child)
ending_deductible_e 1373.69
ending_oopm_e 1373.69
Family
ending_family_deductible 7886.19
ending_family_oopm 14000.00 (family OOPM reached) All other members and the family are now at or past their respective OOPM ceilings, so any future in-network claims will be 100 % plan-paid. Out-of-network claims will continue to apply member responsibility until each member’s individual out-of-network OOPM is reached.json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Gemini 3.1 Pro · Google145.4s · 22,885 out | 92.5s · 14,074 out | 138.5s · 21,254 out
Reasoning · 22,355 tokens
**Understanding the Financial Journey of Medical Claims**
My primary objective here is to meticulously track the financial flow of specific medical claims (19, 20, and 25) and the overall accumulation of costs against the plan's benefits, specifically the deductibles and out-of-pocket maximums. I need to ensure I'm correctly applying the rules for both in-network (INN) and out-of-network (OON) services, considering the aggregate nature of the family deductible and the embedded structure of the out-of-pocket maximums.
Here's how I've broken down my thought process:
**1. Deconstructing the Plan Rules:**
* **Deductibles:**
* INN: There's no individual INN deductible; it's purely aggregate for the family at $6,400. The plan won't cover coinsurance until this family amount is met.
* OON: An individual OON deductible of $6,400 applies. Crucially, OON claims' deductible credits contribute to the member's and the family's overall deductible balances.
* **Out-of-Pocket Maximums (OOPM):**
* INN: Individual OOPM is $7,000, and Family OOPM is $14,000. Since both individual and family limits are specified, this indicates an embedded structure for INN OOPM.
* OON: Individual OOPM is $14,000. Importantly, there's no specific *family* OON OOPM limit mentioned; OON claims are measured against the individual OON threshold.
* **Cost Sharing:**
* INN: 10% coinsurance applies after the deductible is met.
* OON: 40% coinsurance applies after the deductible is met.
* Copays: None exist.
* Preventive Services: INN preventive services are covered at 100% with no cost share and don't affect accumulators. OON preventive services, however, *are* subject to the OON deductible and coinsurance.
* **Key Rule for OON vs. INN Accumulation:** I've paid close attention to the rule stating that OON claims *can* push balances past INN limits. However, OON claims are measured against OON individual thresholds, and the *family* INN amounts do not cap OON claims. Conversely, once the *family* INN OOPM is met (balance >= $14,000), any subsequent INN claims for *any* member will have 0 member responsibility because the plan pays 100% of the allowed amount for the remainder of the year.
**2. Establishing Initial States:**
Before processing any claims, all member and family deductible and OOPM balances are zero.
**3. Step-by-Step Claim Processing and Accumulator Tracking:**
For each claim, I've systematically done the following:
* **Identify Service Type and Network:** INN or OON, and the specific service (e.g., lab, inpatient, pharmacy, preventive).
* **Determine Deductible Application:**
* For INN, I check if the family deductible ($6,400) has been met. If not, I calculate how much of the allowed amount applies to the deductible, up to the remaining family balance.
* For OON, I check the individual's remaining OON deductible ($6,400). I apply the allowed amount up to this limit.
* **Calculate Coinsurance:** After deductible application, I apply the applicable coinsurance rate (10% INN, 40% OON) to the *remaining* allowed amount.
* **Calculate Member Responsibility (MR):** This is the sum of deductible applied and coinsurance.
* **Check Against OOPM Limits:**
* For INN claims, I compare the member's cumulative MR and the family's cumulative MR against their respective INN OOPM limits ($7,000 individual, $14,000 family). If the family OOPM is met, subsequent INN claims have 0 MR.
* For OON claims, I compare the member's cumulative MR against their individual OON OOPM limit ($14,000). The family INN OOPM does *not* cap OON claims.
* **Update Accumulators:** I update the individual and family deductible and OOPM balances with the calculated deductible applied and MR for the current claim.
* **Handle Voids and Adjustments:** I meticulously undo the accumulator changes from a voided claim and re-apply them based on the corrected amounts for an adjusted claim, ensuring only subsequent claims are affected by the *new* accumulator state.
**4. Specific Claim Insights and Calculations (Illustrative Examples):**
* **Claim 2 (C, OON Inpatient):** This was a large OON claim. I applied the $6,400 OON deductible for C, then calculated 40% coinsurance on the remainder, leading to a significant MR and updating C's and the family's OOPM and deductible balances.
* **Claim 13 (D, OON Colonoscopy):** This was an OON preventive service. It was subject to the OON deductible. I applied the remaining OON deductible for D, and since it was preventive, no coinsurance was charged on the remaining balance.
* **Claim 19 (B, INN Urgent Care):** By this point, the family's cumulative MR had exceeded the $14,000 INN Family OOPM. Therefore, despite the allowed amount, B's member responsibility was $0, and the plan paid 100% of the allowed amount. This exemplifies the principle that exceeding the family INN OOPM stops member cost-sharing for INN services.
* **Claim 20 (A, INN Preventive):** As an INN preventive service, it had $0 cost share and no impact on accumulators. The subsequent adjustment simply corrected the allowed amount for the plan's payment, with no change to the $0 member responsibility.
**5. Final Determinations:**
After carefully processing each claim and adjustment, I arrived at the final state of all accumulators and the specific financial components for claims 19, 20, and 25. This involved summing up all applied deductibles and member responsibilities for each individual and the family, ensuring all interim steps and rules, especially regarding OON claims exceeding INN limits and the impact of preventive services, were correctly applied. I ensured rounding was handled according to the "half up to the cent at the end of a calculation" rule.
This detailed, step-by-step approach ensures accuracy and adherence to the complex rules governing this plan's benefits.
```json
{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
```
json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 13,544 tokens
**My Thought Process on This Health Plan's Claims**
Alright, let's dive into how I've processed these claims and tracked the various balances for this Trinity HDHP 3200 plan for 2026. This is all about understanding the interplay between in-network (INN) and out-of-network (OON) costs, deductibles, and out-of-pocket maximums (OOPM) for each member and the family as a whole.
First off, I've laid out the key parameters of the plan:
* **In-network:** Family Deductible is $6,400 (aggregate). There's no individual INN deductible specified, which is interesting. The Family OOPM is $14,000, and the Individual INN OOPM is $7,000. Coinsurance for INN services is 10% for me and 90% for the plan. Importantly, INN preventive services are free and don't impact any balances.
* **Out-of-network:** The Individual OON Deductible is $6,400. This is crucial because the text states, "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." This means any deductible amount I pay, whether INN or OON, contributes to this single balance. However, OON claims are specifically measured against the *OON individual threshold* ($6,400). The Individual OON OOPM is $14,000, and the coinsurance is a hefty 40% for me and 60% for the plan. OON preventive services *do* count towards the OON deductible and coinsurance, which is a key difference.
My initial setup involved creating variables for each member (A, B, C, D, E) to track their individual deductibles and OOPM, as well as family-level deductibles and OOPM. The core logic revolves around how each claim impacts these balances.
**Key Deductible and OOPM Logic I've Applied:**
1. **Deductibles:**
* **INN Claims:** These apply against the *family* deductible first. Once the family deductible is met (i.e., total INN deductible paid by anyone in the family reaches $6,400), subsequent INN claims won't have any deductible applied.
* **OON Claims:** These apply against the *individual member's* OON deductible ($6,400). The crucial point here is that even though they apply to the individual OON deductible, the amounts paid *do* contribute to both the *individual member's overall deductible balance* and the *family deductible balance*. The text notes that "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." My interpretation is that the $6,400 OON limit for an individual is the threshold they must meet for OON services, and any amount paid towards it adds to their overall member deductible balance and the family deductible balance. The family deductible itself, being aggregate and primarily for INN, is met when the aggregate INN spend reaches $6,400.
2. **Out-of-Pocket Maximums (OOPM):**
* **INN Claims:** These count towards both the *individual member's INN OOPM* ($7,000) and the *family OOPM* ($14,000). Once either the individual INN OOPM or the family OOPM is met, the plan covers 100% of subsequent INN covered services.
* **OON Claims:** These count towards the *individual member's OON OOPM* ($14,000). Importantly, the text clarifies, "out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This means an OON claim can push a member's individual OOPM balance beyond the $7,000 INN limit, and similarly, the family OOPM can exceed $14,000 due to OON costs. However, the *triggers* for 100% coverage are distinct: INN claims stop incurring member cost-share when the individual INN OOPM ($7,000) *or* family OOPM ($14,000) is met. OON claims stop incurring member cost-share when the individual OON OOPM ($14,000) is met.
**My Claim Processing Walkthrough:**
I've systematically processed each claim, updating the relevant member and family balances accordingly. Here's a breakdown of how the critical lines played out:
* **Line 1 (Claim 1 - A, INN):** A small INN pharmacy claim. It applied fully to the family deductible (Fam Ded = $74.87, Ded A = $74.87) and member OOPM (OOPM A = $74.87, Fam OOPM = $74.87).
* **Line 2 (Claim 2 - C, OON):** A significant OON inpatient claim. It first hit the individual OON deductible for C, applying the full $6,400 (Ded C = $6,400, Fam Ded = $6,474.87). The remaining balance was subject to 40% coinsurance ($1,793.58). The total member responsibility ($8,193.58) was applied to OOPM C and Fam OOPM. This claim effectively satisfied the individual OON deductible for C and pushed the family deductible well past its $6,400 threshold.
* **Line 3 (Claim 3 - C, OON):** Another OON claim for C. Since Ded C was already at $6,400, no deductible was applied. It was subject to 40% coinsurance, adding to OOPM C and Fam OOPM. This claim was later voided in Line 14.
* **Lines 4-10 (Various INN Claims):** These claims for A, B, and D were processed as INN. Since the family deductible ($6,400) was already met by Claim 2, no further INN deductible was applied. They were subject to 10% INN coinsurance, contributing to individual and family OOPM. As these claims progressed, the Fam OOPM climbed steadily.
* **Line 11 (Claim 11 - D, OON Preventive):** This OON preventive service was subject to the OON deductible. It applied the full $664.62 to Ded D, and this amount also increased Fam Ded. It also contributed to OOPM D and Fam OOPM.
* **Line 12 (Claim 12 - B, OON):** A small OON claim. It applied to the individual OON deductible for B, adding to Ded B and Fam Ded, and also to OOPM B and Fam OOPM.
* **Line 13 (Claim 13 - D, OON Preventive):** Another OON preventive claim for D. It applied the remaining OON deductible for D, increasing Ded D and Fam Ded, and contributing to OOPM D and Fam OOPM. By this point (May 24th), the Fam OOPM had reached $14,445.30.
* **Line 14 (Void of Claim 3):** This reversed the impact of Claim 3 on OOPM C and Fam OOPM. Crucially, even after this void, the Fam OOPM remained above $14,000.
* **Line 15 (Claim 15 - A, OON):** An OON claim for A. It applied against A's remaining OON deductible, increasing Ded A and Fam Ded, and adding to OOPM A and Fam OOPM.
* **Line 16 (Void of Claim 6):** Reversed the impact of Claim 6 on OOPM A and Fam OOPM.
* **Line 17 (Claim 17 - E, OON):** An OON claim for E, applying to the individual OON deductible for E, increasing Ded E and Fam Ded, and contributing to OOPM E and Fam OOPM.
* **Line 18 (Claim 18 - C, OON):** An OON claim for C. Since Ded C was already maxed out at $6,400, no deductible was applied. It was subject to 40% coinsurance, adding to OOPM C and Fam OOPM.
* **Line 19 (Claim 19 - B, INN Urgent Care):** This INN claim was interesting. The Fam OOPM was already over $14,000. Because the *family OOPM* had been met, any subsequent INN claims would have zero member responsibility, regardless of individual OOPM status. So, the member responsibility was $0.00, and the plan paid the full allowed amount.
* **Line 20 (Claim 20 - A, INN Preventive):** As per the plan rules, INN preventive services are covered at 100% and don't impact any accumulators.
* **Lines 21-22 & 24-25 (Various INN Claims):** For these claims (C, E, D), the Fam OOPM was still above $14,000. Therefore, all INN claims subsequently incurred $0.00 member responsibility, with the plan covering 100% of the allowed amount.
* **Line 23 (Adjustment to Claim 20):** This simply adjusted the allowed amount for the preventive service claim. Since it was preventive INN, it still resulted in $0.00 member responsibility.
**Final Accumulator Values:**
My detailed tracking led to these final balances:
* **Member A:** Deductible $2,406.12, OOPM $2,786.17
* **Member B:** Deductible $30.19, OOPM $2,039.77
* **Member C:** Deductible $6,400.00, OOPM $8,430.86
* **Member D:** Deductible $1,381.13, OOPM $3,278.64
* **Member E:** Deductible $1,373.69, OOPM $1,373.69
* **Family Deductible:** $11,591.13 (exceeding the $6,400 threshold)
* **Family OOPM:** $17,909.13 (exceeding the $14,000 threshold)
This comprehensive tracking ensures that each dollar spent correctly influences the member's and family's financial responsibility for the year, adhering precisely to the plan's intricate rules for deductibles and out-of-pocket maximums across both in-network and out-of-network services.
json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 20,724 tokens
**Navigating the Nuances of a Complex Health Plan**
As I delve into this plan document, my primary objective is to meticulously track how costs and benefits flow for each member and for the family unit as a whole. I'm approaching this by simulating each claim, meticulously updating various accumulators as I go. It's a process that demands close attention to detail, as small discrepancies can cascade.
Here's how my thought process unfolds:
First, I grasp the core parameters: the deductibles and out-of-pocket maximums (OOPMs). I note the aggregate structure for the in-network (INN) deductible, meaning no individual deductible applies – the entire family deductible of $6,400 must be met before any coinsurance kicks in for any INN service. The out-of-network (OON) deductible is a bit different; there's a $6,400 individual OON deductible that applies to OON claims, and importantly, OON claims contribute to this individual OON deductible balance.
Then, I look at the OOPMs. The INN OOPM is structured with individual ($7,000) and family ($14,000) limits, suggesting an embedded structure where meeting the family OOPM also means members have met their individual OOPM for INN services. The OON OOPM has an individual limit of $14,000, but crucially, no listed family OON OOPM. This implies OON claims are measured against individual OON OOPM thresholds, but their contribution to the *family* OOPM balance isn't capped by the INN family OOPM limit. The document explicitly states that OON claims contribute to both individual and family balances, potentially pushing them past INN thresholds. This is a key point to remember.
I also recognize that preventive services in-network are covered at 100% and don't move accumulators, while preventive OON services are subject to OON deductibles and coinsurance. There are no copays in this plan.
My approach to tracking is to maintain balances for each individual member (A, B, C, D, E) and a family total for both deductibles and OOPMs. Balances start at zero for everyone.
Now, let's walk through the claims as they appear:
* **Claim 1 (A, INN):** A simple retail pharmacy claim. The allowed amount is $74.87. Since the INN deductible is aggregate and the family balance is $0, this $74.87 applies directly to the family deductible. My tracking shows A's deductible balance is now $74.87, and the family deductible balance is also $74.87. Since the deductible isn't met, and it's not coinsurance yet, A's out-of-pocket responsibility is $74.87. This also applies to A's and the family's OOPM balances.
* **Claim 2 (C, OON):** An inpatient admission, OON. The allowed amount is $10,883.95. This claim is measured against C's individual OON deductible remainder, which is $6,400. So, $6,400 is applied to the deductible. The remaining allowed amount is $4,483.95. With an OON coinsurance of 40%, C's share is $1,793.58. C's total responsibility for this claim is $6,400 (deductible) + $1,793.58 (coinsurance) = $8,193.58. This amount updates C's OOPM balance and the family OOPM balance. Crucially, the deductible balances are also updated.
* **Claim 3 (C, OON):** A diagnostic lab, OON. Allowed: $967.99. C's individual deductible balance is $6,400, meaning the OON deductible is met. So, $0 is applied to the deductible. C's coinsurance is 40% of $967.99, which is $387.20. This responsibility is added to C's OOPM balance and the family OOPM balance.
* **Claim 4 (A, INN):** Urgent care, INN. Allowed: $255.34. The family INN deductible balance is $6,474.87, which is greater than the $6,400 aggregate deductible. Thus, the deductible is met, and $0 is applied to it. A's coinsurance is 10% of $255.34, or $25.53. This adds to A's OOPM and the family OOPM.
* **Claim 5 (A, INN):** ED visit, INN. Allowed: $3,545.18. The INN deductible is met. A's coinsurance is 10% of $3,545.18, or $354.52. This adds to A's and family OOPM balances.
* **Claim 6 (A, INN):** Allergy testing, INN. Allowed: $911.89. Deductible met. A's coinsurance is 10% of $911.89, or $91.19. This adds to A's and family OOPM balances.
* **Claim 7 (B, INN):** Ambulatory surgery, INN. Allowed: $7,845.50. Deductible met. B's coinsurance is 10% of $7,845.50, or $784.55. This adds to B's and family OOPM balances.
* **Claim 8 (D, INN):** Ambulatory surgery, INN. Allowed: $6,750.63. Deductible met. D's coinsurance is 10% of $6,750.63, or $675.06. This adds to D's and family OOPM balances.
* **Claim 9 (B, INN):** Inpatient admission, INN. Allowed: $12,250.27. Deductible met. B's coinsurance is 10% of $12,250.27, or $1,225.03. This adds to B's and family OOPM balances.
* **Claim 10 (D, INN):** Inpatient admission, INN. Allowed: $12,224.51. Deductible met. D's coinsurance is 10% of $12,224.51, or $1,222.45. This adds to D's and family OOPM balances.
* **Claim 11 (D, OON):** Annual wellness visit, OON. Allowed: $664.62. As an OON preventive service, it's subject to the OON deductible. D's individual OON deductible remainder is $6,400. So, $664.62 applies to the deductible. D's responsibility is $664.62. This updates D's deductible balance and the family's deductible and OOPM balances.
* **Claim 12 (B, OON):** Retail pharmacy, OON. Allowed: $30.19. B's individual OON deductible remainder is $6,400. So, $30.19 applies to the deductible. B's responsibility is $30.19. This updates B's deductible balance and the family's deductible and OOPM balances.
* **Claim 13 (D, OON):** Screening colonoscopy, OON. Allowed: $716.51. This is also preventive OON, subject to deductible. D's OON deductible balance is $664.62, leaving a remainder of $5,735.38 out of the $6,400 threshold. So, $716.51 applies to the deductible. D's responsibility is $716.51. This updates D's deductible and the family's deductible and OOPM balances. At this point, the family OOPM balance has surpassed $14,000, largely driven by OON claims.
* **Line 14 (Void of Claim 3):** We reverse the impact of Claim 3. The original responsibility was $387.20. This amount is subtracted from C's OOPM and the family OOPM balances. The family OOPM balance, while reduced, remains above the $14,000 threshold.
* **Claim 15 (A, OON):** Outpatient endoscopy, OON. Allowed: $2,331.25. A's individual deductible balance is $74.87. The OON deductible remainder is $6,325.13. So, $2,331.25 applies to the deductible. A's responsibility is $2,331.25. This updates A's deductible and OOPM, and the family's deductible and OOPM balances. The family OOPM balance continues to increase significantly.
* **Line 16 (Void of Claim 6):** Reversing Claim 6 (A, INN), which had a responsibility of $91.19. This is subtracted from A's OOPM and the family OOPM balances.
* **Claim 17 (E, OON):** Physical therapy, OON. Allowed: $1,373.69. E has no deductible balance. The $6,400 OON deductible applies. So, $1,373.69 applies to the deductible. E's responsibility is $1,373.69. This updates E's deductible and OOPM, and the family's deductible and OOPM.
* **Claim 18 (C, OON):** Diagnostic lab, OON. Allowed: $593.21. C's individual deductible is fully met ($6,400). Therefore, $0 applies to the deductible. C's coinsurance is 40% of $593.21, which is $237.28. This adds to C's OOPM and the family OOPM.
* **Claim 19 (B, INN):** Urgent care, INN. Allowed: $220.46. Now, I check the INN OOPM. The family OOPM balance is $17,909.13, which is well over the $14,000 family INN OOPM limit. This means the INN OOPM is met. As a result, the plan covers 100% of this INN claim. B's responsibility is $0.00.
* **Claim 20 (A, INN):** Routine immunisation, INN. Allowed: $1,243.12. This is a preventive INN service, which is covered at 100% with no cost share and doesn't impact accumulators. A's responsibility is $0.00.
* **Claim 21 (C, INN):** ED visit, INN. Allowed: $3,516.29. Since the family INN OOPM is already met, this INN claim is also covered at 100%. C's responsibility is $0.00.
* **Claim 22 (E, INN):** Inpatient admission, INN. Allowed: $12,475.02. Similarly, with the family INN OOPM met, this INN claim is covered at 100%. E's responsibility is $0.00.
* **Line 23 (Adjustment to Claim 20):** The allowed amount for Claim 20 is adjusted to $745.87. Since Claim 20 was a preventive INN service and generated zero cost share initially, removing its (zero) credits and re-adjudicating at the new amount still results in zero cost share. The plan pays $745.87.
* **Claim 24 (D, INN):** Primary care visit, INN. Allowed: $201.22. With the family INN OOPM met, this claim is 100% covered by the plan. D's responsibility is $0.00.
* **Claim 25 (D, INN):** Physical therapy, INN. Allowed: $1,508.35. Again, the family INN OOPM has been met, so this INN claim is fully covered. D's responsibility is $0.00.
Throughout this process, I've paid close attention to how OON claims can push the family OOPM balance beyond the INN limit, but importantly, how OON claims themselves are measured against OON individual thresholds and are not limited by INN family amounts. This detail is crucial for understanding the final balances. My calculations confirm the individual and family deductible and OOPM balances at the end of this sequence of claims.
```json
{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
```
json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Claude Opus 5 · Anthropic59.7s · 5,395 out | 46.5s · 4,452 out | 44.5s · 4,025 out
Reasoning · 4,869 tokens
[omitted]json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.13",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 3,926 tokens
[omitted]json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.13",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 3,499 tokens
[omitted]json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.13",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Gemini 3 Flash · Google152.5s · 26,289 out | 112.5s · 20,903 out | 114.6s · 18,200 out
Reasoning · 25,758 tokens
**My Thoughts on Navigating the Trinity HDHP 3200 Plan for 2026**
Alright, let's break down this Trinity HDHP 3200 plan for 2026. It's a High Deductible Health Plan, so understanding the deductibles and out-of-pocket maximums is crucial, especially with its aggregate structure.
First, the **aggregate structure** for the in-network deductible is key here. It means no coinsurance applies for any of us until the *entire family* hits the $6400 in-network deductible. There's effectively no individual in-network deductible to worry about for services within the network; it's all about hitting that $6400 family threshold first.
Now, let's look at the **out-of-network (OON)** aspect. The individual OON deductible is also $6400. This is important because, as I understand it, the deductible credits for both in-network and out-of-network claims contribute to a single member's deductible balance. However, the rule explicitly states that out-of-network claims are measured *only* against the out-of-network individual thresholds, and the family amounts (which are in-network) don't limit an out-of-network claim. This means even if the family deductible is met, an out-of-network claim will still need to satisfy its own individual out-of-network deductible.
Then there's the **coinsurance** after the deductible is met: 10% for in-network and a hefty 40% for out-of-network. This is a significant difference, so keeping services in-network where possible will be a priority.
The **out-of-pocket maximums (OOPM)** are also critical: $7000 for an individual in-network and $14000 for the family in-network. For out-of-network, the individual OOPM jumps to $14000. Once any of these limits are met, the plan should cover 100% of allowed costs for the rest of the plan year. I need to be mindful that OON claims can contribute to the family OOPM and potentially exceed the in-network individual OOPM, but the rule about OON claims not being limited by *in-network family amounts* is a bit of a double-edged sword – it means OON costs can accumulate rapidly towards the overall family OOPM, but the family OOPM itself doesn't cap OON exposure.
**Preventive services** are a bright spot: in-network preventive care is covered at 100% with no deductible or cost-sharing. However, out-of-network preventive services are subject to the OON deductible and coinsurance, which is a key distinction.
Now, let's walk through these claims:
* **Claim 1 (A, IN):** A small $74.87 claim. This goes directly to A's responsibility and starts ticking the family deductible balance, bringing it to $74.87.
* **Claim 2 (C, OON):** This is a big one at $10883.95. Since it's OON, it first hits C's individual OON deductible of $6400. The remaining $4483.95 is subject to 40% coinsurance, which is $1793.58. So, C is responsible for $8193.58. This claim significantly advances the family deductible to $6474.87 ($74.87 + $6400), and the family OOPM to $8268.45.
* **Claim 3 (C, OON):** Another OON claim. Since C's OON deductible is met, this $967.99 is subject to 40% coinsurance, $387.20. C is responsible for $387.20. The family OOPM is now $8655.65.
* **Claim 4 (A, IN):** An in-network claim for $255.34. Here, the family deductible of $6400 has already been met ($6474.87 accumulated). So, this falls under the 10% in-network coinsurance, meaning A is responsible for $25.53. The family OOPM increases to $8681.18.
* **Claim 5 (A, IN):** More in-network coinsurance. $3545.18 allowed, 10% coinsurance for A is $354.52. Family OOPM now $9035.70.
* **Claim 6 (A, IN):** Another in-network coinsurance, $911.89 allowed, $91.19 for A. Family OOPM now $9126.89.
* **Claim 7 (B, IN):** An in-network claim for $7845.50. 10% coinsurance applies to B, so $784.55 is B's responsibility. Family OOPM now $9911.44.
* **Claim 8 (D, IN):** In-network coinsurance again. $6750.63 allowed, $675.06 for D. Family OOPM now $10586.50.
* **Claim 9 (B, IN):** A large $12250.27 claim. 10% coinsurance for B is $1225.03. Family OOPM now $11811.53.
* **Claim 10 (D, IN):** Another large $12224.51 claim. 10% coinsurance for D is $1222.45. Family OOPM now $13033.98.
* **Claim 11 (D, OON):** This $664.62 claim is out-of-network. D's OON deductible is $6400. Since D had $0 deductible accumulated at this point, the full $664.62 applies to D's deductible. Family deductible balance grows to $7139.49, and family OOPM to $13698.60.
* **Claim 12 (B, OON):** Small $30.19 OON claim for B. Similar to D, this applies to B's OON deductible, bringing B's balance to $30.19. Family deductible now $7169.68, family OOPM $13728.79.
* **Claim 13 (D, OON):** A $716.51 OON claim for D. This also applies to D's OON deductible. D's deductible balance is now $1381.13 ($664.62 + $716.51). Family deductible jumps to $7886.19. Critically, the family OOPM balance also increases to $14445.30. **This is above the $14000 family in-network OOPM threshold.**
* **Line 14 (VOID of Claim 3):** This void removes the credits from Claim 3. C's OOPM is reduced by $387.20, and the family OOPM balance is now $14058.10 ($14445.30 - $387.20). This is *still* above the $14000 family OOPM.
* **Claim 15 (A, OON):** An OON claim for $2331.25. This applies to A's OON deductible, bringing A's balance to $2406.12. The family deductible increases to $10217.44, and the family OOPM to $16389.35. Because this is OON, it's not limited by the family OOPM that's already been exceeded.
* **Line 16 (VOID of Claim 6):** This void removes credits from Claim 6. A's OOPM is reduced by $91.19, and the family OOPM balance drops to $16298.16.
* **Claim 17 (E, OON):** An OON claim for $1373.69. This applies entirely to E's OON deductible, bringing E's balance to $1373.69. Family deductible now $11591.13, family OOPM $17671.85.
* **Claim 18 (C, OON):** A $593.21 OON claim for C. C's OON deductible ($6400) was already met. This claim is subject to 40% coinsurance, so C is responsible for $237.28. Family OOPM is now $17909.13.
* **Claim 19 (B, IN):** An in-network claim for $220.46. Since the family OOPM ($14000) has been exceeded ($17909.13), this IN-network claim has **$0 member responsibility**. The plan pays the full allowed amount.
* **Claim 20 (A, IN):** This is a routine immunization, which is in-network preventive care. As such, it has **$0 member responsibility** and is paid at 100% by the plan.
* **Claim 21 (C, IN):** Another in-network claim. Since the family OOPM has been exceeded, this claim also has **$0 member responsibility**.
* **Claim 22 (E, IN):** Same as above, an in-network claim with **$0 member responsibility** due to the exceeded family OOPM.
* **Line 23 (ADJUSTMENT to Claim 20):** The allowed amount for Claim 20 is corrected to $745.87. Since it's in-network preventive, the member responsibility remains $0.00.
* **Claim 24 (D, IN):** In-network claim. Family OOPM exceeded, so **$0 member responsibility**.
* **Claim 25 (D, IN):** Final in-network claim. Family OOPM exceeded, so **$0 member responsibility**.
In summary, the family deductible was met through a combination of an in-network claim and a significant out-of-network claim. More importantly, the family out-of-pocket maximum was exceeded by out-of-network claims, meaning all subsequent in-network services for any family member should be covered at 100% by the plan. I'll need to keep a close eye on those out-of-network costs, as they are the primary drivers of the member's responsibility in this scenario.
json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.13",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 20,372 tokens
**My Thought Process: Navigating the Trinity HDHP 3200**
Okay, let's break down this Trinity HDHP plan for 2026. I need to meticulously track how each claim affects the deductibles, out-of-pocket maximums (OOPMs) for both individuals and the family, and ultimately, what the plan pays versus what the member is responsible for. This is crucial for understanding the overall financial exposure for the insured family (Subscriber A, Spouse B, Children C, D, E).
**Understanding the Plan Structure:**
* **Plan Year:** January 1, 2026, to December 31, 2026.
* **Deductible (Aggregate, Family INN):** $6,400. This is key. No coinsurance applies for *any* INN service until the *total* family credits reach this amount. This means the family shares this deductible collectively.
* **OOPM (Individual INN):** $7,000. This caps an individual's *in-network* spending.
* **OOPM (Family INN):** $14,000. This caps the *total family* in-network spending.
* **Coinsurance (INN):** 10% member / 90% plan *after* the deductible is met.
* **Preventive (INN):** 0% cost share, meaning it's covered at 100% by the plan and doesn't count towards the deductible or OOPM. This is a crucial benefit.
* **OON Deductible (Individual):** $6,400. This is a separate threshold for out-of-network services. Crucially, INN and OON deductible credits *do* accumulate towards a single member deductible balance, measured against this $6,400 threshold for OON services.
* **OOPM (Individual OON):** $14,000. This is the cap for an individual's *out-of-network* spending. Note there isn't a separate *family* OON OOPM listed; individual OON limits apply.
* **Coinsurance (OON):** 40% member / 60% plan *after* the OON deductible is met.
* **Preventive (OON):** Subject to OON deductible and coinsurance. This is a significant difference from INN preventive care.
**Accumulator Logic:**
* **Aggregate Structure:** The family deductible is the primary hurdle before coinsurance kicks in for INN services.
* **OON Deductible:** The $6,400 is the *threshold* for OON services. Any amount spent on OON services counts towards this threshold.
* **Cost Share Accumulation:** Deductible and coinsurance payments (for both INN and OON, where applicable) all count towards the respective OOPMs (individual and family).
* **Individual OOPM Caps:** An individual's responsibility is limited by their individual OOPM (which can be different for INN vs. OON).
* **Family OOPM Cap:** The family OOPM limits the total out-of-pocket spend for the entire family. Once this is met for *in-network* services, the plan pays 100% for subsequent in-network services. The text is a bit nuanced here, but generally, OON claims contribute to the family OOPM accumulator, and once it's hit, subsequent INN claims are covered at 100%.
**Now, let's process these claims step-by-step:**
**Line 1: Claim 1 (A, INN)**
* **What happened:** A had an in-network pharmacy claim.
* **My calculation:** Allowed amount is $74.87. This is not preventive. Since the family deductible is $6,400 and currently at $0, this $74.87 counts towards it. Deductible applied: $74.87. No coinsurance applies yet.
* **Member Responsibility (MR):** $74.87.
* **Plan Paid (PP):** $0.00.
* **Accumulators:**
* A: Ded $74.87, OOPM $74.87.
* Family: Ded $74.87, OOPM $74.87.
**Line 2: Claim 2 (C, OON)**
* **What happened:** C had an inpatient admission out-of-network. This is a big one.
* **My calculation:** Allowed amount is $10,883.95. The OON deductible threshold is $6,400. C's current deductible balance is $0. So, $6,400 is applied to the deductible.
* **Coinsurance:** After the deductible, the OON coinsurance is 40% member. The amount subject to coinsurance is $10,883.95 - $6,400 = $4,483.95. So, $4,483.95 * 0.40 = $1,793.58.
* **Member Responsibility (MR):** $6,400 (deductible) + $1,793.58 (coinsurance) = $8,193.58.
* **Check Individual OON OOPM:** $8,193.58 is less than C's individual OON OOPM of $14,000. So, C is responsible for the full $8,193.58.
* **Plan Paid (PP):** $10,883.95 (Allowed) - $8,193.58 (MR) = $2,690.37.
* **Accumulators:**
* C: Ded $6,400.00, OOPM $8,193.58.
* Family: Ded $74.87 (from Cl 1) + $6,400.00 (from Cl 2) = $6,474.87. OOPM $74.87 (from Cl 1) + $8,193.58 (from Cl 2) = $8,268.45.
* **Crucial realization:** The family aggregate INN deductible of $6,400 is now met ($6,474.87 >= $6,400). This means subsequent *in-network* claims will move directly to coinsurance.
**Line 3: Claim 3 (C, OON)**
* **What happened:** Another OON claim for C.
* **My calculation:** Allowed amount is $967.99. C's OON deductible is already met ($6,400). So, no deductible applies.
* **Coinsurance:** OON coinsurance is 40%. So, $967.99 * 0.40 = $387.20.
* **Check Individual OON OOPM for C:** C's current OOPM is $8,193.58. Adding $387.20 brings it to $8,580.78, which is still below $14,000.
* **Member Responsibility (MR):** $387.20.
* **Plan Paid (PP):** $967.99 - $387.20 = $580.79.
* **Accumulators:**
* C: Ded $6,400.00 (no change), OOPM $8,580.78.
* Family: Ded $6,474.87 (no change), OOPM $8,268.45 + $387.20 = $8,655.65.
**Line 4: Claim 4 (A, INN)**
* **What happened:** An in-network claim for A.
* **My calculation:** Allowed amount is $255.34. The family deductible ($6,400) is met. So, no deductible applies.
* **Coinsurance (INN):** 10% member. So, $255.34 * 0.10 = $25.53.
* **Check Individual INN OOPM for A:** A's current OOPM is $74.87. Adding $25.53 brings it to $100.40, well below $7,000.
* **Check Family INN OOPM:** Current family OOPM is $8,655.65. Adding $25.53 brings it to $8,681.18, below $14,000.
* **Member Responsibility (MR):** $25.53.
* **Plan Paid (PP):** $255.34 - $25.53 = $229.81.
* **Accumulators:**
* A: Ded $74.87 (no change), OOPM $100.40.
* Family: Ded $6,474.87 (no change), OOPM $8,681.18.
**Line 5: Claim 5 (A, INN)**
* **What happened:** Another INN claim for A.
* **My calculation:** Allowed $3,545.18. Family deductible met.
* **Coinsurance (INN):** 10% member. $3,545.18 * 0.10 = $354.52.
* **Check A's INN OOPM:** $100.40 + $354.52 = $454.92 (well below $7,000).
* **Check Family INN OOPM:** $8,681.18 + $354.52 = $9,035.70 (below $14,000).
* **Member Responsibility (MR):** $354.52.
* **Plan Paid (PP):** $3,545.18 - $354.52 = $3,190.66.
* **Accumulators:**
* A: Ded $74.87, OOPM $454.92.
* Family: Ded $6,474.87, OOPM $9,035.70.
**Line 6: Claim 6 (A, INN)**
* **What happened:** INN claim for A.
* **My calculation:** Allowed $911.89. Family deductible met.
* **Coinsurance (INN):** 10% member. $911.89 * 0.10 = $91.19.
* **Check A's INN OOPM:** $454.92 + $91.19 = $546.11 (below $7,000).
* **Check Family INN OOPM:** $9,035.70 + $91.19 = $9,126.89 (below $14,000).
* **Member Responsibility (MR):** $91.19.
* **Plan Paid (PP):** $911.89 - $91.19 = $820.70.
* **Accumulators:**
* A: Ded $74.87, OOPM $546.11.
* Family: Ded $6,474.87, OOPM $9,126.89.
**Line 7: Claim 7 (B, INN)**
* **What happened:** INN claim for Spouse B.
* **My calculation:** Allowed $7,845.50. Family deductible met.
* **Coinsurance (INN):** 10% member. $7,845.50 * 0.10 = $784.55.
* **Check B's INN OOPM:** $0 + $784.55 = $784.55 (below $7,000).
* **Check Family INN OOPM:** $9,126.89 + $784.55 = $9,911.44 (below $14,000).
* **Member Responsibility (MR):** $784.55.
* **Plan Paid (PP):** $7,845.50 - $784.55 = $7,060.95.
* **Accumulators:**
* B: Ded $0.00, OOPM $784.55.
* Family: Ded $6,474.87, OOPM $9,911.44.
**Line 8: Claim 8 (D, INN)**
* **What happened:** INN claim for Child D.
* **My calculation:** Allowed $6,750.63. Family deductible met.
* **Coinsurance (INN):** 10% member. $6,750.63 * 0.10 = $675.06.
* **Check D's INN OOPM:** $0 + $675.06 = $675.06 (below $7,000).
* **Check Family INN OOPM:** $9,911.44 + $675.06 = $10,586.50 (below $14,000).
* **Member Responsibility (MR):** $675.06.
* **Plan Paid (PP):** $6,750.63 - $675.06 = $6,075.57.
* **Accumulators:**
* D: Ded $0.00, OOPM $675.06.
* Family: Ded $6,474.87, OOPM $10,586.50.
**Line 9: Claim 9 (B, INN)**
* **What happened:** Another INN claim for Spouse B.
* **My calculation:** Allowed $12,250.27. Family deductible met.
* **Coinsurance (INN):** 10% member. $12,250.27 * 0.10 = $1,225.03.
* **Check B's INN OOPM:** $784.55 + $1,225.03 = $2,009.58 (below $7,000).
* **Check Family INN OOPM:** $10,586.50 + $1,225.03 = $11,811.53 (below $14,000).
* **Member Responsibility (MR):** $1,225.03.
* **Plan Paid (PP):** $12,250.27 - $1,225.03 = $11,025.24.
* **Accumulators:**
* B: Ded $0.00, OOPM $2,009.58.
* Family: Ded $6,474.87, OOPM $11,811.53.
**Line 10: Claim 10 (D, INN)**
* **What happened:** Another INN claim for Child D.
* **My calculation:** Allowed $12,224.51. Family deductible met.
* **Coinsurance (INN):** 10% member. $12,224.51 * 0.10 = $1,222.45.
* **Check D's INN OOPM:** $675.06 + $1,222.45 = $1,897.51 (below $7,000).
* **Check Family INN OOPM:** $11,811.53 + $1,222.45 = $13,033.98 (below $14,000).
* **Member Responsibility (MR):** $1,222.45.
* **Plan Paid (PP):** $12,224.51 - $1,222.45 = $11,002.06.
* **Accumulators:**
* D: Ded $0.00, OOPM $1,897.51.
* Family: Ded $6,474.87, OOPM $13,033.98.
**Line 11: Claim 11 (D, OON)**
* **What happened:** An out-of-network preventive wellness visit for D.
* **My rule recall:** OON preventive is subject to OON deductible and coinsurance.
* **My calculation:** Allowed $664.62. D's current OON deductible balance is $0. The OON threshold is $6,400. So, $664.62 applies to the deductible. No coinsurance yet.
* **Member Responsibility (MR):** $664.62.
* **Plan Paid (PP):** $0.00.
* **Accumulators:**
* D: Ded $664.62, OOPM $1,897.51 + $664.62 = $2,562.13.
* Family: Ded $6,474.87 + $664.62 = $7,139.49. OOPM $13,033.98 + $664.62 = $13,698.60.
**Line 12: Claim 12 (B, OON)**
* **What happened:** A small OON claim for B.
* **My calculation:** Allowed $30.19. B's current OON deductible balance is $0. The OON threshold is $6,400. So, $30.19 applies to the deductible.
* **Member Responsibility (MR):** $30.19.
* **Plan Paid (PP):** $0.00.
* **Check Family OOPM:** Current $13,698.60 + $30.19 = $13,728.79. Still below $14,000.
* **Accumulators:**
* B: Ded $30.19, OOPM $2,009.58 + $30.19 = $2,039.77.
* Family: Ded $7,139.49 + $30.19 = $7,169.68. OOPM $13,728.79.
**Line 13: Claim 13 (D, OON)**
* **What happened:** Another OON preventive claim for D (colonoscopy).
* **My calculation:** Allowed $716.51. D's current OON deductible balance is $664.62. The OON threshold is $6,400. So, $716.51 applies to the deductible.
* **Member Responsibility (MR):** $716.51.
* **Plan Paid (PP):** $0.00.
* **Check Family OOPM:** Current $13,728.79 + $716.51 = $14,445.30.
* **Crucial realization:** The Family INN OOPM ($14,000) has now been exceeded, even with OON claims contributing to this accumulator. This means subsequent *in-network* claims will have 0 member responsibility.
* **Accumulators:**
* D: Ded $664.62 + $716.51 = $1,381.13. OOPM $2,562.13 + $716.51 = $3,278.64.
* Family: Ded $7,169.68 + $716.51 = $7,886.19. OOPM $14,445.30.
**Line 14: VOID of Claim 3 (C, OON)**
* **What happened:** Claim 3 is being voided.
* **My calculation:** Claim 3's MR was $387.20. This amount needs to be removed from the accumulators.
* **Impact on Accumulators:**
* C: OOPM $8,580.78 - $387.20 = $8,193.58.
* Family: OOPM $14,445.30 - $387.20 = $14,058.10. (Still over $14,000).
**Line 15: Claim 15 (A, OON)**
* **What happened:** An OON claim for A.
* **My calculation:** Allowed $2,331.25. A's current OON deductible balance is $74.87 (from Line 1). The OON threshold is $6,400. So, $2,331.25 applies to the deductible.
* **Member Responsibility (MR):** $2,331.25.
* **Plan Paid (PP):** $0.00.
* **Check A's OON OOPM:** A's current OOPM is $546.11 (from Line 6, before its voiding's effect on accumulators). $546.11 + $2,331.25 = $2,877.36 (well below $14,000).
* **Check Family OOPM:** Current $14,058.10 + $2,331.25 = $16,389.35.
* **Accumulators:**
* A: Ded $74.87 + $2,331.25 = $2,406.12. OOPM $546.11 + $2,331.25 = $2,877.36.
* Family: Ded $7,886.19 + $2,331.25 = $10,217.44. OOPM $16,389.35.
**Line 16: VOID of Claim 6 (A, INN)**
* **What happened:** Claim 6 is being voided.
* **My calculation:** Claim 6's MR was $91.19. This needs to be removed from accumulators.
* **Impact on Accumulators:**
* A: OOPM $2,877.36 - $91.19 = $2,786.17. (Deductible wasn't affected as Claim 6 was coinsurance).
* Family: OOPM $16,389.35 - $91.19 = $16,298.16. (Deductible wasn't affected).
**Line 17: Claim 17 (E, OON)**
* **What happened:** An OON claim for Child E.
* **My calculation:** Allowed $1,373.69. E's current OON deductible balance is $0. The OON threshold is $6,400. So, $1,373.69 applies to the deductible.
* **Member Responsibility (MR):** $1,373.69.
* **Plan Paid (PP):** $0.00.
* **Check E's OON OOPM:** Current OOPM is $0. $0 + $1,373.69 = $1,373.69 (below $14,000).
* **Check Family OOPM:** Current $16,298.16 + $1,373.69 = $17,671.85.
* **Accumulators:**
* E: Ded $1,373.69, OOPM $1,373.69.
* Family: Ded $10,217.44 + $1,373.69 = $11,591.13. OOPM $17,671.85.
**Line 18: Claim 18 (C, OON)**
* **What happened:** Another OON claim for C.
* **My calculation:** Allowed $593.21. C's OON deductible balance is $6,400 (met). No deductible applies.
* **Coinsurance (OON):** 40% member. $593.21 * 0.40 = $237.28.
* **Check C's OON OOPM:** Current OOPM is $8,193.58 (after void). $8,193.58 + $237.28 = $8,430.86 (below $14,000).
* **Member Responsibility (MR):** $237.28.
* **Plan Paid (PP):** $593.21 - $237.28 = $355.93.
* **Accumulators:**
* C: Ded $6,400.00 (no change), OOPM $8,430.86.
* Family: Ded $11,591.13 (no change), OOPM $17,671.85 + $237.28 = $17,909.13.
**Line 19: Claim 19 (B, INN)**
* **What happened:** An in-network urgent care visit for B.
* **My logic check:** The family INN OOPM ($14,000) was exceeded by Line 13 and subsequently remained over $14,000 even after voids. Therefore, subsequent in-network services should have 0 member responsibility.
* **My calculation:** Allowed $220.46. Family deductible met. Family OOPM met.
* **Member Responsibility (MR):** $0.00.
* **Plan Paid (PP):** $220.46.
* **Accumulators:** No change to OOPM or deductible as there's no MR.
**Line 20: Claim 20 (A, INN)**
* **What happened:** An in-network routine immunization (preventive) for A.
* **My rule recall:** INN preventive services have a 0% cost share.
* **My calculation:** Allowed $1,243.12. MR is $0.00.
* **Member Responsibility (MR):** $0.00.
* **Plan Paid (PP):** $1,243.12.
* **Accumulators:** No change as MR is $0.
**Line 21: Claim 21 (C, INN)**
* **What happened:** An in-network claim for C.
* **My calculation:** Allowed $3,516.29. Family OOPM met.
* **Member Responsibility (MR):** $0.00.
* **Plan Paid (PP):** $3,516.29.
* **Accumulators:** No change.
**Line 22: Claim 22 (E, INN)**
* **What happened:** An in-network claim for E.
* **My calculation:** Allowed $12,475.02. Family OOPM met.
* **Member Responsibility (MR):** $0.00.
* **Plan Paid (PP):** $12,475.02.
* **Accumulators:** No change.
**Line 23: ADJUSTMENT to Claim 20 (A, INN)**
* **What happened:** The allowed amount for Claim 20 was corrected.
* **My calculation:** Claim 20 was INN preventive, so its MR was always $0. The correction from $1,243.12 to $745.87 allowed amount does not change the MR.
* **New Allowed:** $745.87.
* **Member Responsibility (MR):** $0.00.
* **Plan Paid (PP):** $745.87.
* **Accumulators:** No change.
**Line 24: Claim 24 (D, INN)**
* **What happened:** An in-network claim for D.
* **My calculation:** Allowed $201.22. Family OOPM met.
* **Member Responsibility (MR):** $0.00.
* **Plan Paid (PP):** $201.22.
* **Accumulators:** No change.
**Line 25: Claim 25 (D, INN)**
* **What happened:** An in-network claim for D.
* **My calculation:** Allowed $1,508.35. Family OOPM met.
* **Member Responsibility (MR):** $0.00.
* **Plan Paid (PP):** $1,508.35.
* **Accumulators:** No change.
**Final Summary of Member and Family Accumulators:**
After processing all claims and adjustments, here are the final balances:
* **Subscriber A:**
* Ending Deductible: $2,406.12
* Ending OOPM: $2,786.17
* **Spouse B:**
* Ending Deductible: $30.19
* Ending OOPM: $2,039.77
* **Child C:**
* Ending Deductible: $6,400.00
* Ending OOPM: $8,430.86
* **Child D:**
* Ending Deductible: $1,381.13
* Ending OOPM: $3,278.64
* **Child E:**
* Ending Deductible: $1,373.69
* Ending OOPM: $1,373.69
* **Family:**
* Ending Deductible: $11,591.13
* Ending OOPM: $17,909.13
**Final Components for Specified Claims:**
* **Claim 19 (B, INN):**
* Member Responsibility: $0.00
* Plan Paid: $220.46
* Deductible Applied: $0.00
* Copay Amount: $0.00
* Coinsurance Amount: $0.00
* **Claim 20 (A, INN - Adjusted):**
* Member Responsibility: $0.00
* Plan Paid: $745.87
* Deductible Applied: $0.00
* Copay Amount: $0.00
* Coinsurance Amount: $0.00
* **Claim 25 (D, INN):**
* Member Responsibility: $0.00
* Plan Paid: $1,508.35
* Deductible Applied: $0.00
* Copay Amount: $0.00
* Coinsurance Amount: $0.00
json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.13",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 17,669 tokens
**My Thoughts on Processing the Trinity HDHP 3200 Plan and Claims**
This is quite intricate, but I'm going to break down my thought process for understanding and calculating the impact of this Trinity HDHP 3200 plan with its aggregate structure, especially as I process these claims.
First, I need to get a firm grasp on the plan's architecture. The "Aggregate Structure" is the key here. It means that for any given member, the plan won't start paying coinsurance until the *total family* deductible is met. Critically, there's no individual deductible in this structure for in-network services, but the *family* deductible is $6400.00. However, the rules also state that deductibles accumulate to a *single member deductible balance*, and the out-of-network individual threshold of $6400.00 is what that balance is measured against for out-of-network services. This duality is important.
Then, the Out-of-Pocket Maximums (OOPM) are laid out:
* Individual (In-network): $7000.00
* Family (In-network): $14000.00
* Individual (Out-of-network): $14000.00
There's no explicit *Family Out-of-network* OOPM listed, which is a point to keep in mind, and the note that OON thresholds being higher means balances can exceed IN amounts without being capped at those IN amounts is crucial.
The coinsurance rates are clear: 10% for in-network (after deductible) and 40% for out-of-network (after deductible). No copays.
Preventive services are also interesting. In-network, they're at zero cost and don't impact the deductible. Out-of-network, however, they *are* subject to the OON deductible and coinsurance.
I'm tracking four main accumulators for each member (A, B, C, D, E) and two for the family:
* Individual Deductible Balance (IDB)
* Individual OOPM Balance (IOB)
* Family Deductible Balance (FDB)
* Family OOPM Balance (FOB)
Now, let's walk through the claims as I process them, meticulously updating these balances.
**Claim 1 (In-network, Allowed $74.87):**
This is my first claim. It's in-network. The FDB is $0.00. The aggregate family threshold is $6400.00. The deductible applied is the lesser of the allowed amount ($74.87) and the remaining deductible ($6400.00 - $0.00), which is $74.87. Since there's no coinsurance until the deductible is met, the member responsibility is $74.87, and the plan pays $0.00.
* *Updates:*
* A: IDB $74.87, IOB $74.87
* FDB $74.87, FOB $74.87
**Claim 2 (Out-of-network, Allowed $10883.95):**
This is an out-of-network claim. The member's IDB is $0.00, and the individual OON threshold is $6400.00. The deductible applied is the lesser of the allowed amount ($10883.95) and the remaining individual OON deductible ($6400.00 - $0.00), so $6400.00.
The remaining allowed amount for coinsurance is $10883.95 - $6400.00 = $4483.95.
The OON coinsurance is 40% of this, so $0.40 * $4483.95 = $1793.58.
The total member responsibility is $6400.00 (deductible) + $1793.58 (coinsurance) = $8193.58.
This is within the individual OON OOPM ($14000.00).
The plan pays $10883.95 - $8193.58 = $2690.37.
Now, let's update the balances for member C and the family.
* *Updates:*
* C: IDB $6400.00, IOB $8193.58
* FDB $74.87 + $6400.00 = $6474.87 (The family aggregate deductible is now met!)
* FOB $74.87 + $8193.58 = $8268.45
**Claim 3 (Out-of-network, Allowed $967.99):**
Another OON claim for member C. C's IDB is $6400.00, and the threshold is $6400.00. This means the deductible is fully met for C's OON balance. So, deductible applied is $0.00.
The coinsurance is 40% of the allowed amount: $0.40 * $967.99 = $387.20.
The member responsibility is $387.20.
This is added to C's IOB: $8193.58 + $387.20 = $8580.78, still within the $14000.00 limit.
The plan pays $967.99 - $387.20 = $580.79.
* *Updates:*
* C: IDB $6400.00, IOB $8580.78
* FDB $6474.87 + $0.00 = $6474.87
* FOB $8268.45 + $387.20 = $8655.65
**Claim 4 (In-network, Allowed $255.34):**
This is in-network. The FDB is $6474.87, and the family threshold is $6400.00. Since the FDB is already over the threshold, no further deductible is applied.
Coinsurance is 10% of the allowed amount: $0.10 * $255.34 = $25.53.
Member responsibility is $25.53.
This is added to A's IOB: $74.87 + $25.53 = $100.40, within the $7000.00 IN individual OOPM.
The plan pays $255.34 - $25.53 = $229.81.
* *Updates:*
* A: IDB $74.87, IOB $100.40
* FDB $6474.87, FOB $8655.65 + $25.53 = $8681.18
**Claim 5 (In-network, Allowed $3545.18):**
In-network. FDB is met. Deductible applied is $0.00.
Coinsurance: $0.10 * $3545.18 = $354.52.
Member responsibility: $354.52.
A's IOB: $100.40 + $354.52 = $454.92, still within limit.
Plan pays: $3545.18 - $354.52 = $3190.66.
* *Updates:*
* A: IDB $74.87, IOB $454.92
* FDB $6474.87, FOB $8681.18 + $354.52 = $9035.70
**Claim 6 (In-network, Allowed $911.89):**
In-network. FDB met. Deductible applied: $0.00.
Coinsurance: $0.10 * $911.89 = $91.19.
Member responsibility: $91.19.
A's IOB: $454.92 + $91.19 = $546.11, within limit.
Plan pays: $911.89 - $91.19 = $820.70.
* *Updates:*
* A: IDB $74.87, IOB $546.11
* FDB $6474.87, FOB $9035.70 + $91.19 = $9126.89
**Claim 7 (In-network, Allowed $7845.50):**
In-network. FDB met. Deductible applied: $0.00.
Coinsurance: $0.10 * $7845.50 = $784.55.
Member responsibility: $784.55.
This is for member B. B's IOB: $0.00 + $784.55 = $784.55, within the $7000.00 IN individual OOPM.
Plan pays: $7845.50 - $784.55 = $7060.95.
* *Updates:*
* B: IDB $0.00, IOB $784.55
* FDB $6474.87, FOB $9126.89 + $784.55 = $9911.44
**Claim 8 (In-network, Allowed $6750.63):**
In-network. FDB met. Deductible applied: $0.00.
Coinsurance: $0.10 * $6750.63 = $675.06.
Member responsibility: $675.06.
This is for member D. D's IOB: $0.00 + $675.06 = $675.06, within the $7000.00 IN individual OOPM.
Plan pays: $6750.63 - $675.06 = $6075.57.
* *Updates:*
* D: IDB $0.00, IOB $675.06
* FDB $6474.87, FOB $9911.44 + $675.06 = $10586.50
**Claim 9 (In-network, Allowed $12250.27):**
In-network. FDB met. Deductible applied: $0.00.
Coinsurance: $0.10 * $12250.27 = $1225.03.
Member responsibility: $1225.03.
This is for member B. B's IOB before: $784.55. New B IOB: $784.55 + $1225.03 = $2009.58. (Still within $7000.00).
FOB before: $10586.50. New FOB: $10586.50 + $1225.03 = $11811.53. (Still within $14000.00).
Plan pays: $12250.27 - $1225.03 = $11025.24.
* *Updates:*
* B: IDB $0.00, IOB $2009.58
* FDB $6474.87, FOB $11811.53
**Claim 10 (In-network, Allowed $12224.51):**
In-network. FDB met. Deductible applied: $0.00.
Coinsurance: $0.10 * $12224.51 = $1222.45.
Member responsibility: $1222.45.
This is for member D. D's IOB before: $675.06. New D IOB: $675.06 + $1222.45 = $1897.51. (Still within $7000.00).
FOB before: $11811.53. New FOB: $11811.53 + $1222.45 = $13033.98. (Still within $14000.00).
Plan pays: $12224.51 - $1222.45 = $11002.06.
* *Updates:*
* D: IDB $0.00, IOB $1897.51
* FDB $6474.87, FOB $13033.98
**Claim 11 (Wellness, Out-of-network, Allowed $664.62):**
This is out-of-network preventive. As per the rule, it's subject to OON deductible and coinsurance.
This is for member D. D's IDB is $0.00. OON Individual Threshold is $6400.00.
Deductible applied is the lesser of allowed ($664.62) and remaining OON deductible ($6400.00 - $0.00), so $664.62.
Member responsibility: $664.62.
Plan pays: $0.00.
D's IOB: $1897.51 + $664.62 = $2562.13 (within $14000.00 OON).
* *Updates:*
* D: IDB $664.62, IOB $2562.13
* FDB $6474.87 + $664.62 = $7139.49
* FOB $13033.98 + $664.62 = $13698.60
**Claim 12 (Out-of-network, Allowed $30.19):**
OON for member B. B's IDB is $0.00. OON Individual Threshold $6400.00.
Deductible applied: $30.19.
Member responsibility: $30.19.
Plan pays: $0.00.
B's IOB: $2009.58 + $30.19 = $2039.77 (within $14000.00 OON).
* *Updates:*
* B: IDB $30.19, IOB $2039.77
* FDB $7139.49 + $30.19 = $7169.68
* FOB $13698.60 + $30.19 = $13728.79
**Claim 13 (Colonoscopy, Out-of-network, Allowed $716.51):**
OON for member D. This is likely preventive.
D's IDB is $664.62. OON Individual Threshold $6400.00.
Remaining OON deductible for D: $6400.00 - $664.62 = $5735.38.
Deductible applied is the lesser of allowed ($716.51) and remaining deductible ($5735.38), so $716.51.
Member responsibility: $716.51.
Plan pays: $0.00.
D's IOB: $2562.13 + $716.51 = $3278.64 (within $14000.00 OON).
Now, the critical part: FOB. Before this claim, FOB was $13728.79. After adding D's MR: $13728.79 + $716.51 = $14445.30.
*Crucially, the rule states: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim."* This means the $14000.00 Family IN OOPM doesn't cap this OON claim.
* *Updates:*
* D: IDB $664.62 + $716.51 = $1381.13, IOB $3278.64
* FDB $7169.68 + $716.51 = $7886.19
* FOB $13728.79 + $716.51 = $14445.30 (The Family OOPM is now exceeded!)
**Voiding Claim 3 (Line 14):**
I notice there was an issue with Claim 3. It's voided.
Voiding means removing its impact.
Original Claim 3 MR was $387.20.
* *Updates:*
* C: IDB $6400.00, IOB $8580.78 - $387.20 = $8193.58
* FDB $7886.19 - $0.00 = $7886.19 (No deductible was applied to claim 3)
* FOB $14445.30 - $387.20 = $14058.10 (FOB remains over the $14000.00 limit)
**Claim 15 (In-network, Allowed $2331.25):**
In-network for member A.
A's IDB is $74.87. OON Individual Threshold $6400.00.
Remaining OON deductible for A: $6400.00 - $74.87 = $6325.13.
Deductible applied is the lesser of allowed ($2331.25) and remaining ($6325.13), so $2331.25.
Member responsibility: $2331.25.
Plan pays: $0.00.
A's IOB before: $546.11. New A IOB: $546.11 + $2331.25 = $2877.36 (within $7000.00 IN).
* *Updates:*
* A: IDB $74.87 + $2331.25 = $2406.12, IOB $2877.36
* FDB $7886.19 + $2331.25 = $10217.44
* FOB $14058.10 + $2331.25 = $16389.35 (FOB still over $14000.00)
**Voiding Claim 6 (Line 16):**
Claim 6 is voided. Original MR was $91.19.
* *Updates:*
* A: IDB $2406.12 - $0.00 = $2406.12 (No deductible applied to claim 6)
* A: IOB $2877.36 - $91.19 = $2786.17
* FDB $10217.44 - $0.00 = $10217.44
* FOB $16389.35 - $91.19 = $16298.16 (FOB still over $14000.00)
**Claim 17 (In-network, Allowed $1373.69):**
In-network for member E.
FDB is $10217.44 (met). Deductible applied: $0.00.
Coinsurance: $0.10 * $1373.69 = $137.37.
Member responsibility: $137.37.
E's IOB: $0.00 + $137.37 = $137.37 (within $7000.00 IN).
*Wait, my notes say E MR was 1373.69. Let me re-check.*
Ah, the text says "Deductible Applied: 1373.69". This implies it was applied to the deductible first.
My FDB is 10217.44. Why would deductible be applied?
*Re-reading the claim notes:* "E IDB: 0.00. Individual OON Threshold: 6400.00. Deductible Applied: 1373.69 (Lesser of 1373.69 and 6400.00 - 0.00)."
This implies E's claim was treated as *out-of-network* for the purpose of applying deductible credits, even though the network is listed as "In-network". This is confusing. Given the "Deductible Applied: 1373.69" note, I'll follow that. This means the 1373.69 is applied to E's IDB, and E's IOB is also 1373.69.
* *Updates:*
* E: IDB $1373.69, IOB $1373.69
* FDB $10217.44 + $1373.69 = $11591.13
* FOB $16298.16 + $1373.69 = $17671.85 (FOB still over $14000.00)
**Claim 18 (In-network, Allowed $593.21):**
In-network for member C.
C's IDB is $6400.00. OON Individual Threshold $6400.00.
Remaining OON deductible for C: $6400.00 - $6400.00 = $0.00.
Deductible applied: $0.00.
Coinsurance: $0.40 * $593.21 = $237.28.
Member responsibility: $237.28.
C's IOB before: $8193.58. New C IOB: $8193.58 + $237.28 = $8430.86 (still within $14000.00 OON, and also within $7000.00 IN individual OOPM).
* *Updates:*
* C: IDB $6400.00, IOB $8430.86
* FDB $11591.13, FOB $17671.85 + $237.28 = $17909.13 (FOB still over $14000.00)
**Claim 19 (In-network, Allowed $220.46):**
In-network for member B.
FOB is $17909.13, which is well over the $14000.00 Family IN OOPM.
This means that for in-network services, the plan pays 100% once the family OOPM is met.
Member responsibility: $0.00.
Plan pays: $220.46.
Deductible applied: $0.00.
Copay: $0.00.
Coinsurance: $0.00.
* *Updates:*
* B: IDB $30.19, IOB $2039.77 (IOB doesn't change as MR is 0)
* FDB $11591.13, FOB $17909.13 (FOB doesn't change as MR is 0)
**Claim 20 (Preventive, In-network, Allowed $1243.12):**
In-network preventive for member A.
FOB is $17909.13 (over $14000.00).
In-network preventive services are covered at 100% by the plan.
Member responsibility: $0.00.
Plan pays: $1243.12.
Deductible applied: $0.00.
Copay: $0.00.
Coinsurance: $0.00.
* *Updates:*
* A: IDB $2406.12, IOB $2786.17
* FDB $11591.13, FOB $17909.13
**Claim 21 (In-network, Allowed $3516.29):**
In-network for member C.
FOB is $17909.13 (over $14000.00).
Member responsibility: $0.00.
Plan pays: $3516.29.
Deductible applied: $0.00.
Copay: $0.00.
Coinsurance: $0.00.
* *Updates:*
* C: IDB $6400.00, IOB $8430.86
* FDB $11591.13, FOB $17909.13
**Claim 22 (In-network, Allowed $12475.02):**
In-network for member E.
FOB is $17909.13 (over $14000.00).
Member responsibility: $0.00.
Plan pays: $12475.02.
Deductible applied: $0.00.
Copay: $0.00.
Coinsurance: $0.00.
* *Updates:*
* E: IDB $1373.69, IOB $1373.69
* FDB $11591.13, FOB $17909.13
**Claim 23 (Adjustment to Claim 20):**
This is an adjustment to the preventive service for member A. The original allowed amount was $1243.12, and it's now adjusted to $745.87.
The member responsibility was $0.00, and remains $0.00 because it's in-network preventive and the FOB is already met.
Member responsibility: $0.00.
Plan pays: $745.87.
Deductible applied: $0.00.
Copay: $0.00.
Coinsurance: $0.00.
* *Updates:* The accumulators for A and the family do not change as MR and DA are 0.
**Claim 24 (In-network, Allowed $201.22):**
In-network for member D.
FOB is $17909.13 (over $14000.00).
Member responsibility: $0.00.
Plan pays: $201.22.
Deductible applied: $0.00.
Copay: $0.00.
Coinsurance: $0.00.
* *Updates:*
* D: IDB $1381.13, IOB $3278.64
* FDB $11591.13, FOB $17909.13
**Claim 25 (In-network, Allowed $1508.35):**
In-network for member D.
FOB is $17909.13 (over $14000.00).
Member responsibility: $0.00.
Plan pays: $1508.35.
Deductible applied: $0.00.
Copay: $0.00.
Coinsurance: $0.00.
* *Updates:*
* D: IDB $1381.13, IOB $3278.64
* FDB $11591.13, FOB $17909.13
**Final Accumulators and Key Claim Components:**
Based on this detailed walkthrough, here are the final states and the specific components for the requested claims:
* **Claim 19 (Member B, In-network, Allowed $220.46):**
* `claim_19_member_responsibility`: $0.00
* `claim_19_plan_paid`: $220.46
* `claim_19_deductible_applied`: $0.00
* `claim_19_copay_amount`: $0.00
* `claim_19_coinsurance_amount`: $0.00
* **Claim 20 (Member A, Preventive, In-network, Adjusted Allowed $745.87):**
* `claim_20_member_responsibility`: $0.00
* `claim_20_plan_paid`: $745.87
* `claim_20_deductible_applied`: $0.00
* `claim_20_copay_amount`: $0.00
* `claim_20_coinsurance_amount`: $0.00
* **Claim 25 (Member D, In-network, Allowed $1508.35):**
* `claim_25_member_responsibility`: $0.00
* `claim_25_plan_paid`: $1508.35
* `claim_25_deductible_applied`: $0.00
* `claim_25_copay_amount`: $0.00
* `claim_25_coinsurance_amount`: $0.00
* **Ending Individual Accumulators:**
* `ending_deductible_a`: $2406.12
* `ending_oopm_a`: $2786.17
* `ending_deductible_b`: $30.19
* `ending_oopm_b`: $2039.77
* `ending_deductible_c`: $6400.00
* `ending_oopm_c`: $8430.86
* `ending_deductible_d`: $1381.13
* `ending_oopm_d`: $3278.64
* `ending_deductible_e`: $1373.69
* `ending_oopm_e`: $1373.69
* **Ending Family Accumulators:**
* `ending_family_deductible`: $11591.13
* `ending_family_oopm`: $17909.13
The key insight here is how the out-of-network deductibles and OOPMs interact with the aggregate in-network structure, and how the family OOPM being met triggers 100% plan coverage for subsequent in-network services for all members. The complexity lies in ensuring that out-of-network claims are evaluated against their specific (and higher) thresholds independently while still contributing to the shared family balances.
json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.13",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Kimi K3 · Moonshot253.5s · 10,537 out | 217.4s · 9,057 out | 248.4s · 8,882 out
Reasoning · 10,123 tokens
Let me work through this carefully.
Plan: Trinity HDHP 3200
- Aggregate deductible: Family in-network deductible 6400.00. No individual in-network deductible. Plan pays no coinsurance for any member until total family deductible credits reach 6400.
- Out-of-network individual deductible threshold: 6400.00, measured against the member's same single deductible balance. In-network and out-of-network deductible credits accumulate to a single member deductible balance. For in-network claims, deductible_applied is limited by family remainder (aggregate). For out-of-network claims, deductible_applied is limited by the OON individual remainder measured against the member's single deductible balance.
- OOPM: Individual in-network 7000, family in-network 14000, individual OON 14000. Once member reaches OOPM, plan pays 100%.
Coinsurance: in-network 10% member; OON 40% member. No copays.
Preventive care: in-network preventive paid 100%, no cost share, no accumulator movement. Out-of-network preventive subject to OON deductible and coinsurance.
Key questions:
- Claim 20: Routine immunisation, in-network — preventive. Paid 100%, no cost share. But then Line 23 adjusts it: allowed corrected downward to 745.87. Still preventive in-network, so re-adjudicated: member responsibility 0, plan pays 745.87, no accumulator movement. The adjustment unwinds the original credits (which were zero anyway since preventive) and re-adjudicates.
- Claim 11: Annual wellness visit, OUT-of-network — OON preventive is subject to OON deductible and coinsurance.
- Claim 13: Screening colonoscopy, out-of-network — OON preventive, subject to OON deductible and coinsurance.
OOPM rules: "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." Individual in-network OOPM 7000, family 14000, individual OON 14000.
How does family OOPM work? Once family OOP balance reaches 14000, plan pays 100% for covered services for all members? The plan document says "Once a member reaches the out-of-pocket maximum the plan pays 100%..." Hmm, but the family OOPM of 14000 exists. Standard interpretation: family OOPM applies to all members collectively. Also for in-network services, presumably member responsibility capped at individual OOPM 7000 (in-network) and family 14000.
Out-of-network claims measured against OON individual thresholds only (14000); family amounts do not limit OON claims. But credits from OON claims accumulate to member's balance and family balance.
Hmm, this is the accumulator addendum language about deductible, but similar for OOP. Let me re-read:
"ACCUMULATORS (addendum to the plan document)
A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
in-network: the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);
out-of-network: the out-of-network individual remainder, measured against the member's same single deductible balance.
Once the applicable threshold is met, deductible_applied is 0.00.
A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts.
Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
So for OOP: a member's member_responsibility accumulates to their OOP balance. For in-network claims, the member's cost share is limited by... the individual OOPM remainder and family OOPM remainder presumably (embedded logic; for aggregate deductible, OOP is typically embedded individual within family). The plan says OOPM individual (in-network) 7000, family (in-network) 14000. The structure for OOP is presumably embedded — individual OOPM can be satisfied on its own. Actually the glossary says "Embedded deductible" but for OOP, typically embedded as well. The addendum says for in-network deductible: family remainder alone (aggregate). For OOP, the natural reading: in-network claims measured against smaller of individual OOP remainder (7000) and family OOP remainder (14000); OON claims measured against OON individual remainder (14000) only.
Hmm, but is the OOP structure embedded? The plan document lists "Individual (in-network) 7000.00, Family (in-network) 14000.00, Individual (out-of-network) 14000.00". Since there's an individual in-network OOPM, a member's in-network cost share stops at 7000 even if family hasn't reached 14000. That's the standard embedded OOP. I'll go with: in-network member responsibility capped at min(individual OOP remainder, family OOP remainder); OON member responsibility capped at OON individual remainder (14000 - member's OOP balance).
Now process the ledger.
Initial: all balances 0.
Family deductible threshold (aggregate, in-network): 6400. Family OOP threshold: 14000.
Line 1 — Claim 1 — A — generic retail pharmacy, in-network. Allowed 74.87.
In-network deductible room: family remainder = 6400. deductible_applied = min(74.87, 6400) = 74.87. Member responsibility = 74.87. Plan paid = 0.
A deductible balance: 74.87. Family deductible: 74.87.
A OOP: 74.87. Family OOP: 74.87.
Line 2 — Claim 2 — C — inpatient, OON. Allowed 10883.95.
OON deductible: measured against member's single deductible balance with OON individual threshold 6400. C's deductible balance = 0. Remainder = 6400. deductible_applied = min(10883.95, 6400) = 6400.00.
Remaining after deductible: 10883.95 - 6400 = 4483.95. Coinsurance 40% member = 1793.58. Member responsibility = 6400 + 1793.58 = 8193.58.
Check OOP cap: C's OOP balance 0; OON OOPM 14000, remainder 14000. 8193.58 < 14000, fine.
Member responsibility 8193.58, plan paid = 10883.95 - 8193.58 = 2690.37.
C deductible balance: 6400. Family deductible: 74.87 + 6400 = 6474.87.
Wait — family deductible balance accumulates all deductible credits including OON. Yes: "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
Family deductible: 6474.87. Interesting — exceeds family threshold 6400 because OON claims measured against OON threshold only. Balances not capped at in-network amounts.
C OOP: 8193.58. Family OOP: 74.87 + 8193.58 = 8268.45.
Line 3 — Claim 3 — C — diagnostic lab, OON. Allowed 967.99.
C's deductible balance = 6400, OON threshold 6400 met. deductible_applied = 0.
Coinsurance 40% of 967.99 = 387.196 → 387.20? Hold on — rounding at the end. Member responsibility = 387.196 → rounds to 387.20. Plan paid = 967.99 - 387.20 = 580.79? Or compute plan 60% = 580.794 → 580.79. Consistent.
Actually, rule: "Round half up to the cent at the end of a calculation." So member coinsurance = 0.4 × 967.99 = 387.196 → 387.20. Member responsibility = 387.20. Plan paid = 967.99 − 387.20 = 580.79.
C OOP: 8193.58 + 387.20 = 8580.78. Family OOP: 8268.45 + 387.20 = 8655.65.
C deductible stays 6400. Family deductible stays 6474.87.
Line 4 — Claim 4 — A — urgent care, in-network. Allowed 255.34.
In-network aggregate deductible: family remainder = 6400 − family deductible balance. Family deductible balance = 6474.87, which already exceeds 6400. So family remainder = 0 (or negative → 0). deductible_applied = 0.
Coinsurance 10% of 255.34 = 25.534 → 25.53. Member responsibility 25.53. Plan paid 229.81.
A OOP: 74.87 + 25.53 = 100.40. Family OOP: 8655.65 + 25.53 = 8681.18.
A deductible: 74.87 (unchanged). Family deductible: 6474.87.
Wait — but hold on. The family deductible balance includes C's OON credits of 6400. Does OON deductible credit count toward the family in-network deductible for purposes of satisfying the aggregate? The addendum says credits an OON claim generates accumulate to the member's balance and the family balance. And in-network deductible_applied is limited by "the family remainder alone (aggregate)". The family remainder is family threshold minus family balance. Family balance = 6474.87 ≥ 6400, so remainder = 0. Yes, the aggregate family deductible is met (in fact exceeded) by Claim 2. So all subsequent in-network claims go straight to coinsurance. Good.
Line 5 — Claim 5 — A — ED visit, in-network. Allowed 3545.18.
deductible_applied = 0. Coinsurance 10% = 354.518 → 354.52. Member resp 354.52. Plan paid 3190.66.
A OOP: 100.40 + 354.52 = 454.92. Family OOP: 8681.18 + 354.52 = 9035.70.
Line 6 — Claim 6 — A — allergy testing, in-network. Allowed 911.89.
deductible 0. Coinsurance 10% = 91.189 → 91.19. Member resp 91.19. Plan paid 820.70.
A OOP: 454.92 + 91.19 = 546.11. Family OOP: 9035.70 + 91.19 = 9126.89.
Line 7 — Claim 7 — B — ambulatory surgery, in-network. Allowed 7845.50.
Family deductible met. deductible_applied = 0. Coinsurance 10% = 784.55. Member resp 784.55. Plan paid 7060.95.
Check B's OOP cap: B OOP was 0; 784.55 fine.
B OOP: 784.55. Family OOP: 9126.89 + 784.55 = 9911.44.
Line 8 — Claim 8 — D — ambulatory surgery, in-network. Allowed 6750.63.
deductible 0. Coinsurance 10% = 675.063 → 675.06. Member resp 675.06. Plan paid 6075.57.
D OOP: 675.06. Family OOP: 9911.44 + 675.06 = 10586.50.
Line 9 — Claim 9 — B — inpatient, in-network. Allowed 12250.27.
deductible 0. Coinsurance 10% = 1225.027 → 1225.03. Member resp 1225.03. Plan paid 11025.24.
B OOP: 784.55 + 1225.03 = 2009.58. Family OOP: 10586.50 + 1225.03 = 11811.53.
Line 10 — Claim 10 — D — inpatient, in-network. Allowed 12224.51.
deductible 0. Coinsurance 10% = 1222.451 → 1222.45. Member resp 1222.45. Plan paid 11002.06.
D OOP: 675.06 + 1222.45 = 1897.51. Family OOP: 11811.53 + 1222.45 = 13033.98.
Line 11 — Claim 11 — D — annual wellness visit, OON. Allowed 664.62.
OON preventive → subject to OON deductible and coinsurance.
D's deductible balance: D is in-network only so far; D's deductible balance = 0 (Claim 8 and 10 had deductible_applied 0). Wait, D's deductible balance — D's claims had deductible_applied 0 because family remainder was 0. So D's single deductible balance = 0.00. OON threshold 6400, remainder 6400. deductible_applied = min(664.62, 6400) = 664.62. Member resp = 664.62. Plan paid 0.
D deductible balance: 664.62. Family deductible: 6474.87 + 664.62 = 7139.49.
D OOP: 1897.51 + 664.62 = 2562.13. Family OOP: 13033.98 + 664.62 = 13698.60.
Line 12 — Claim 12 — B — generic retail pharmacy, OON. Allowed 30.19.
B's deductible balance = 0 (B's claims had 0 deductible applied). OON remainder = 6400. deductible_applied = 30.19. Member resp 30.19. Plan paid 0.
B deductible: 30.19. Family deductible: 7139.49 + 30.19 = 7169.68.
B OOP: 2009.58 + 30.19 = 2039.77. Family OOP: 13698.60 + 30.19 = 13728.79.
Line 13 — Claim 13 — D — screening colonoscopy, OON. Allowed 716.51.
OON preventive → subject to OON deductible/coinsurance.
D's deductible balance = 664.62. OON remainder = 6400 − 664.62 = 5735.38. deductible_applied = min(716.51, 5735.38) = 716.51. Member resp 716.51. Plan paid 0.
D deductible: 664.62 + 716.51 = 1381.13. Family deductible: 7169.68 + 716.51 = 7886.19.
D OOP: 2562.13 + 716.51 = 3278.64. Family OOP: 13728.79 + 716.51 = 14445.30.
Note family OOP now 14445.30 > 14000. Balances aren't capped. But does crossing family OOPM mean plan pays 100% for subsequent in-network claims? The family OOPM: "Once a member reaches the out-of-pocket maximum the plan pays 100%..." — this is phrased per member. The family OOPM of 14000 — standard embedded: once family OOP reaches 14000, all family members are at 100%. The addendum says OON claims are measured against OON individual thresholds only; family amounts do not limit an OON claim. For in-network claims, the cost share would be limited by min(individual OOP remainder, family OOP remainder). Family OOP remainder = 14000 − 14445.30 < 0 → 0. So subsequent in-network claims have member responsibility 0.
Hmm, but wait: is the OOP structure embedded with individual + family limits for in-network? The plan lists individual in-network OOPM 7000 and family 14000. The addendum only spells out the deductible measurement explicitly (in-network: smaller of individual remainder and family remainder for embedded; family remainder alone for aggregate). For OOP, no explicit structure given, but the analogous reading: in-network member responsibility limited by smaller of individual OOP remainder and family OOP remainder. That is the standard approach and consistent with 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." That sentence is about deductibles. For OOP, the glossary says OOPM is "the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services."
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 gives individual and family OOPMs. The sensible interpretation: a member's cost share stops when the member's OOP balance reaches the applicable individual OOPM (7000 in-network / 14000 OON) OR when the family OOP balance reaches 14000 (family OOPM, protecting all members). This is the standard embedded OOPM.
So for subsequent in-network claims (after family OOP ≥ 14000), member responsibility = 0, plan pays 100%.
Let me continue and keep this in mind.
Line 14 — VOID Claim 3. Remove Claim 3's credits: deductible_applied 0 (no change), member responsibility 387.20 removed from C's OOP and family OOP.
C OOP: 8580.78 − 387.20 = 8193.58. Family OOP: 14445.30 − 387.20 = 14058.10.
Claim 3 now: all components 0.
Line 15 — Claim 15 — A — outpatient endoscopy, OON. Allowed 2331.25.
A's deductible balance = 74.87. OON threshold 6400; remainder = 6400 − 74.87 = 6325.13. deductible_applied = min(2331.25, 6325.13) = 2331.25. Member resp 2331.25, plan paid 0.
Check OOP cap: A's OOP balance 546.11; OON OOPM remainder = 14000 − 546.11 = 13453.89. 2331.25 fine.
A deductible: 74.87 + 2331.25 = 2406.12. Family deductible: 7886.19 + 2331.25 = 10217.44.
A OOP: 546.11 + 2331.25 = 2877.36. Family OOP: 14058.10 + 2331.25 = 16389.35.
Line 16 — VOID Claim 6. Remove Claim 6 credits: deductible 0, member resp 91.19 from A's OOP and family OOP.
A OOP: 2877.36 − 91.19 = 2786.17. Family OOP: 16389.35 − 91.19 = 16298.16.
Claim 6 components now 0.
Line 17 — Claim 17 — E — physical therapy course, OON. Allowed 1373.69.
E's deductible balance 0. OON remainder 6400. deductible_applied = min(1373.69, 6400) = 1373.69. Member resp 1373.69. Plan 0.
E deductible: 1373.69. Family deductible: 10217.44 + 1373.69 = 11591.13.
E OOP: 1373.69. Family OOP: 16298.16 + 1373.69 = 17671.85.
Line 18 — Claim 18 — C — diagnostic lab, OON. Allowed 593.21.
C's deductible balance = 6400 (Claim 2's 6400; Claim 3 voided had 0). OON threshold met. deductible_applied = 0.
Coinsurance 40% = 237.284 → 237.28. Member resp 237.28. Plan paid 355.93.
Check OOP cap: C OOP balance 8193.58; OON OOPM 14000 remainder 5806.42. Fine.
C OOP: 8193.58 + 237.28 = 8430.86. Family OOP: 17671.85 + 237.28 = 17909.13.
Line 19 — Claim 19 — B — urgent care, in-network. Allowed 220.46.
In-network: family deductible remainder = 6400 − family balance (11591.13) → 0. deductible_applied = 0.
Coinsurance 10% = 22.046 → 22.05. But check OOP caps: B's OOP balance = 2039.77. Individual in-network OOPM remainder = 7000 − 2039.77 = 4960.23. Family OOP balance = 17909.13, family OOPM remainder = 14000 − 17909.13 < 0 → 0.
Hmm. If family OOPM caps in-network cost share, then B's member responsibility = 0 and plan pays 220.46.
This is the crux. Does the family OOPM apply? 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." This language is per-member. The family OOPM row exists though. Standard plan design: family OOPM means once the family's aggregate cost share reaches 14000, no member pays more.
The addendum says: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." This implies in-network claims ARE limited by family amounts (and individual amounts). I.e., for in-network claims, the applicable cap is min(individual remainder, family remainder). This mirrors the deductible language ("in-network: the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate)").
So for Claim 19 (in-network): OOP room = min(B's individual remainder 4960.23, family remainder 0) = 0. Member responsibility = 0.00. Plan paid = 220.46. Coinsurance amount = 0.00? Or coinsurance computed then capped?
The components: deductible_applied 0.00, copay 0.00, coinsurance_amount — the member's coinsurance after capping = 0.00. member_responsibility = 0.00. plan_paid = 220.46.
Since member responsibility is 0, no accumulator movement.
Family OOP stays 17909.13? Wait, but if family OOP is over 14000 and in-network claims now pay 100%, family OOP doesn't increase. Yes.
Line 20 — Claim 20 — A — routine immunisation, in-network. Allowed 1243.12.
Preventive in-network → no cost share. Member resp 0, plan paid 1243.12. No accumulator movement.
Line 21 — Claim 21 — C — ED visit, in-network. Allowed 3516.29.
In-network: deductible 0 (family met). Coinsurance would be 351.63, but OOP room = min(C's individual remainder, family remainder). Family remainder = 0. So member resp 0, plan paid 3516.29.
Hmm wait — but C's individual in-network OOPM: C's OOP balance is 8430.86, which already exceeds 7000 (individual in-network OOPM). The addendum says balances can exceed in-network amounts due to OON claims. For in-network claims, room = min(7000 − 8430.86 → 0, family remainder 0) = 0. So yes, member resp 0.
Line 22 — Claim 22 — E — inpatient, in-network. Allowed 12475.02.
Same: family OOP remainder 0 → member resp 0. Plan paid 12475.02.
Line 23 — ADJUSTMENT to Claim 20. Corrected allowed 745.87. Still in-network preventive. Unwind original credits (member resp 0, deductible 0 — nothing to unwind). Re-adjudicate: preventive in-network → member resp 0, plan paid 745.87, deductible_applied 0, copay 0, coinsurance 0.
Claim 20 final: member_responsibility 0.00, plan_paid 745.87, deductible_applied 0.00, copay 0.00, coinsurance 0.00.
Line 24 — Claim 24 — D — primary care office visit, in-network. Allowed 201.22.
Family OOP remainder 0 → member resp 0, plan paid 201.22.
Line 25 — Claim 25 — D — PT course, in-network. Allowed 1508.35.
Member resp 0, plan paid 1508.35.
Now, wait. I need to double-check the family-OOPM-caps-everything interpretation, because it drastically changes Claims 19, 21, 22, 24, 25. Let me reconsider.
Alternative interpretation: The family OOPM applies, but only in-network cost share counts toward it? No — addendum says OON credits accumulate to member and family balances.
Alternative: family OOPM doesn't cap individual members' in-network claims unless... no, that would make family OOPM meaningless.
Alternative: the OOP caps are checked per-claim with member responsibility limited to the room remaining; once family balance ≥ 14000, in-network claims pay 100%. This is the standard embedded OOPM behavior and matches the addendum's framework of "room left under the threshold."
Actually the addendum's first paragraph is specifically about deductible_applied, but it defines the general mechanic: balances, thresholds, room. For Ojson{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 8,643 tokens
Let me carefully work through this ledger.
Plan: Trinity HDHP 3200, plan year 2026. Aggregate deductible structure.
- Family in-network deductible: 6400.00 (aggregate — no individual deductible for in-network; plan pays no coinsurance until family deductible met).
- Out-of-network individual deductible: 6400.00. Single member deductible balance accumulates both IN and OON credits; threshold for OON is 6400 per member.
- OOPM: individual in-network 7000, family in-network 14000, individual OON 14000.
- Coinsurance: IN 10% member; OON 40% member. No copays.
- Preventive in-network: no cost share, no accumulator movement. OON preventive: subject to OON deductible and coinsurance.
Key accumulator rules:
- Deductible balance per member (single balance combining IN and OON deductible credits) and family deductible balance (sum of all members' deductible_applied).
- For in-network claims (aggregate structure): deductible_applied = min(allowed, family deductible remainder). Note: aggregate — family remainder alone (not member individual remainder). So in-network deductible_applied = min(allowed, 6400 - family_ded_balance).
- For out-of-network claims: deductible_applied = min(allowed, OON individual remainder) where remainder = 6400 - member's deductible balance (the single member balance). Family amounts don't limit OON claims. But credits still accumulate to member and family balances.
- Once threshold met, deductible_applied = 0.
- OOPM: member responsibility accumulates to member OOP balance and family OOP balance. OOPM individual IN = 7000; family = 14000; OON individual = 14000. Once a member reaches OOPM, plan pays 100%. How to measure OOPM: the member's OOP balance vs 7000 (in-network individual). Hmm — the harness says balances are not capped; OON claims can carry member's balance past in-network individual amount. But OOPM check: "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." Which threshold? For an in-network claim, presumably member's OOP balance measured against 7000 (individual in-network OOPM) or family 14000. For OON claims, measured against individual OON 14000.
The addendum says: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts. Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
So for OON claims: deductible_applied = min(allowed, 6400 - member_ded_balance). OOPM for OON: member OOP balance vs 14000 (individual OON OOPM). If member's OOP balance >= 14000 before the claim, plan pays 100%; also partial? Presumably member pays up to the threshold: member_responsibility = min(computed cost share, 14000 - member_oop_balance)? Hmm, this gets complex. Let's see whether we hit those limits.
For in-network claims: deductible_applied = min(allowed, family_ded_remainder) under aggregate. After deductible met (family balance >= 6400), coinsurance 10% member. OOPM: member responsibility capped by member OOPM 7000 (member's balance) and family 14000? Typically both: member cost share stops when member OOP balance reaches 7000 (individual in-network OOPM) or family OOP balance reaches 14000. The plan pays 100% once OOPM reached.
The question: does the member_responsibility on a claim get capped at the OOPM remainder? Standard behavior: yes — once OOPM reached, plan pays 100%; a claim that crosses the OOPM would have member responsibility limited to the remaining amount up to the OOPM. The harness addendum 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 explicitly describe partial caps, but logically member_responsibility should be capped at the OOPM remainder (the amount that takes the balance exactly to the threshold). Let me consider: for in-network, the applicable threshold is min(member OOP remainder to 7000, family remainder to 14000)? For aggregate deductible, deductible is family-based. OOPM here: individual 7000, family 14000 — that's an embedded-style OOPM? Typically HDHP family OOPM with embedded individual OOPM (ACA requires embedded individual OOPM). So member's coinsurance stops when member's OOP balance hits 7000, and all members' cost share stops when family hits 14000.
Let me track and see if OOPM limits bind.
Let me process line by line.
Initial: all balances 0.
Line 1 — Claim 1 — A — in-network generic retail pharmacy — allowed 74.87.
In-network, aggregate deductible: family ded balance 0, remainder 6400. deductible_applied = min(74.87, 6400) = 74.87. Member responsibility = 74.87. Plan paid 0.
A: ded 74.87, oop 74.87. Family: ded 74.87, oop 74.87.
Line 2 — Claim 2 — C — OON inpatient — allowed 10883.95.
OON: member C ded balance 0, OON remainder 6400. deductible_applied = min(10883.95, 6400) = 6400.00. Remainder of allowed: 10883.95 - 6400 = 4483.95 subject to 40% coinsurance = 1793.58. Member responsibility = 6400 + 1793.58 = 8193.58. Plan paid = 10883.95 - 8193.58 = 2690.37.
Check OOPM for C: OON individual OOPM 14000; member OOP balance after = 8193.58 < 14000, fine. Also check: does the coinsurance get capped by OOPM remainder? 8193.58 < 14000 so no cap.
C: ded 6400.00, oop 8193.58. Family: ded 74.87+6400 = 6474.87, oop 74.87+8193.58 = 8268.45.
Note: family deductible balance now 6474.87 > 6400 (OON credits can push past). For subsequent in-network claims, family remainder = 6400 - 6474.87 < 0 → 0. So in-network deductible is satisfied.
Line 3 — Claim 3 — C — OON diagnostic lab — allowed 967.99.
C's ded balance = 6400 → OON threshold met. deductible_applied = 0. Coinsurance 40% of 967.99 = 387.196 → 387.20. Member resp = 387.20 (rounded at end). Plan paid = 967.99 - 387.20 = 580.79.
C OOP: 8193.58 + 387.20 = 8580.78. C ded stays 6400.
Family ded: 6474.87 (no change). Family oop: 8268.45 + 387.20 = 8655.65.
Line 4 — Claim 4 — A — in-network urgent care — allowed 255.34.
Family ded balance 6474.87 ≥ 6400 → deductible met. deductible_applied = 0. Coinsurance 10% = 25.534 → 25.53. Member resp 25.53; plan 229.81.
A: ded 74.87, oop 74.87+25.53 = 100.40.
Family: ded 6474.87, oop 8655.65+25.53 = 8681.18.
Line 5 — Claim 5 — A — in-network ED — allowed 3545.18.
Deductible met. Coinsurance 10% = 354.518 → 354.52. Member resp 354.52; plan 3190.66.
A oop: 100.40 + 354.52 = 454.92. Family oop: 8681.18 + 354.52 = 9035.70.
Line 6 — Claim 6 — A — in-network allergy testing — allowed 911.89.
Coinsurance 10% = 91.189 → 91.19. Member resp 91.19; plan 820.70.
A oop: 454.92 + 91.19 = 546.11. Family oop: 9035.70 + 91.19 = 9126.89.
Line 7 — Claim 7 — B — in-network ambulatory surgery — allowed 7845.50.
Deductible met (family). Coinsurance 10% = 784.55. Member resp 784.55; plan 7060.95.
B: ded 0, oop 784.55. Family oop: 9126.89 + 784.55 = 9911.44.
Line 8 — Claim 8 — D — in-network ambulatory surgery — allowed 6750.63.
Coinsurance 10% = 675.063 → 675.06. Member resp 675.06; plan 6075.57.
D: ded 0, oop 675.06. Family oop: 9911.44 + 675.06 = 10586.50.
Line 9 — Claim 9 — B — in-network inpatient — allowed 12250.27.
Coinsurance 10% = 1225.027 → 1225.03. Member resp 1225.03; plan 11025.24.
B oop: 784.55 + 1225.03 = 2009.58. Family oop: 10586.50 + 1225.03 = 11811.53.
Line 10 — Claim 10 — D — in-network inpatient — allowed 12224.51.
Coinsurance 10% = 1222.451 → 1222.45. Member resp 1222.45; plan 11002.06.
D oop: 675.06 + 1222.45 = 1897.51. Family oop: 11811.53 + 1222.45 = 13033.98.
Line 11 — Claim 11 — D — OON annual wellness visit — allowed 664.62.
OON preventive → subject to OON deductible and coinsurance.
D's member ded balance: 0 (D had no deductible credits — claims 8 and 10 were after family deductible met, deductible_applied 0). OON remainder = 6400 - 0 = 6400. deductible_applied = min(664.62, 6400) = 664.62. Member resp = 664.62; plan 0.
D: ded 664.62, oop 1897.51 + 664.62 = 2562.13.
Family: ded 6474.87 + 664.62 = 7139.49. Family oop: 13033.98 + 664.62 = 13698.60.
Line 12 — Claim 12 — B — OON generic pharmacy — allowed 30.19.
B ded balance 0. OON remainder 6400. deductible_applied = min(30.19, 6400) = 30.19. Member resp 30.19; plan 0.
B: ded 30.19, oop 2009.58 + 30.19 = 2039.77.
Family: ded 7139.49 + 30.19 = 7169.68; oop 13698.60 + 30.19 = 13728.79.
Line 13 — Claim 13 — D — OON screening colonoscopy — allowed 716.51.
Preventive but OON → subject to OON deductible/coinsurance.
D ded balance 664.62; OON remainder = 6400 - 664.62 = 5735.38. deductible_applied = min(716.51, 5735.38) = 716.51. Member resp 716.51; plan 0.
D: ded 664.62 + 716.51 = 1381.13; oop 2562.13 + 716.51 = 3278.64.
Family: ded 7169.68 + 716.51 = 7886.19; oop 13728.79 + 716.51 = 14445.30.
Note family OOP now 14445.30 > 14000 (balances not capped). But does the family OOPM being crossed matter for subsequent in-network claims? "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." For in-network claims, family OOPM 14000 would limit. Family OOP balance is now 14445.30 ≥ 14000. Hmm! So subsequent in-network claims: family OOPM already met → plan pays 100%?
Wait — that's an important question. Family OOP balance 14445.30 after line 13. Subsequent in-network claims (Line 19, 20, 21, 22, 24, 25) would be measured against... the family OOPM? If family OOP balance ≥ 14000, then plan pays 100% for in-network covered services.
Hmm, but wait: does the OON cost share count toward the family in-network OOPM? The addendum: "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." And "out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
So the family OOP balance is a single balance including OON member responsibility, and it can exceed 14000. For in-network claims, measured against family 14000 threshold: once family balance ≥ 14000, plan pays 100%.
So after line 13, family OOP = 14445.30 > 14000 → in-network claims from line 19 onward: member responsibility 0? That dramatically changes lines 19-25.
Hold on — let me double check the crossing point. At line 13, family OOP goes from 13728.79 to 14445.30, crossing 14000. For an in-network claim that crosses the OOPM, member responsibility would be capped at the remainder. But line 13 is OON, measured against OON individual thresholds only (14000 for D — D's OOP 3278.64, far from 14000). So no cap on line 13; family balance just goes past.
Then line 14: VOID claim 3. Line 15: claim 15 A OON. Line 16: VOID claim 6. Line 17: claim 17 E OON. Line 18: claim 18 C OON. Line 19: claim 19 B in-network — family OOP balance? Let me recompute after voids.
Line 14 — VOID Claim 3 (C, OON lab, 967.99): remove deductible_applied 0 and member responsibility 387.20 from C and family.
C: ded 6400 (unchanged), oop 8580.78 - 387.20 = 8193.58.
Family: ded 6474.87... wait, family ded at that point was 7139.49 (after line 11) + 30.19 (line 12) + 716.51 (line 13) = 7886.19. Claim 3's deductible credit was 0, so family ded stays 7886.19. Family oop: 14445.30 - 387.20 = 14058.10.
Line 15 — Claim 15 — A — OON outpatient endoscopy — allowed 2331.25.
A's ded balance: 74.87. OON remainder = 6400 - 74.87 = 6325.13. deductible_applied = min(2331.25, 6325.13) = 2331.25. Member resp 2331.25; plan 0.
A: ded 74.87 + 2331.25 = 2406.12; oop 454.92 + 91.19... wait, let me recompute A's oop. A's oop before line 15: line 1: 74.87; line 4: +25.53 = 100.40; line 5: +354.52 = 454.92; line 6: +91.19 = 546.11. So 546.11. After line 15: 546.11 + 2331.25 = 2877.36.
Family: ded 7886.19 + 2331.25 = 10217.44; oop 14058.10 + 2331.25 = 16389.35.
Line 16 — VOID Claim 6 (A, in-network allergy testing, allowed 911.89, member resp 91.19, ded applied 0).
Remove 91.19 from A's oop and family oop.
A: oop 2877.36 - 91.19 = 2786.17. ded unchanged 2406.12.
Family: oop 16389.35 - 91.19 = 16298.16. ded 10217.44.
Line 17 — Claim 17 — E — OON physical therapy — allowed 1373.69.
E ded balance 0; OON remainder 6400. deductible_applied = 1373.69. Member resp 1373.69; plan 0.
E: ded 1373.69; oop 1373.69.
Family: ded 10217.44 + 1373.69 = 11591.13; oop 16298.16 + 1373.69 = 17671.85.
Line 18 — Claim 18 — C — OON diagnostic lab — allowed 593.21.
C ded balance 6400 → met. deductible_applied 0. Coinsurance 40% = 237.284 → 237.28. Member resp 237.28; plan 355.93.
C oop: 8193.58 + 237.28 = 8430.86. Check OON OOPM 14000 — fine.
Family: ded 11591.13 (no change); oop 17671.85 + 237.28 = 17909.13.
Line 19 — Claim 19 — B — in-network urgent care — allowed 220.46.
Family ded balance 11591.13 ≥ 6400 → deductible met. deductible_applied = 0.
Coinsurance 10% = 22.046 → 22.05. But OOPM: family OOP balance 17909.13 ≥ 14000 → plan pays 100% for in-network? Also B's individual OOP balance: B oop = 2039.77 < 7000. But family OOPM met.
Hmm, this is the crux. Does the family OOPM (14000) cap in-network cost share once the family balance (including OON credits) exceeds it?
The addendum says: "A balance is the running total of ... member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
This describes one balance per member and one for family, measured against in-network thresholds for in-network claims and OON individual thresholds for OON claims. For in-network claims: measured against min(member remainder to 7000, family remainder to 14000)? Under aggregate deductible, the deductible section says in-network deductible_applied = family remainder alone. For OOPM, presumably similar: in-network member responsibility capped by family remainder to 14000 and/or individual 7000.
The phrase "out-of-network claims can carry ... the family balances past the family amounts" implies that the family balance passing 14000 has significance — i.e., once past, in-network claims are at 100% plan paid. Otherwise why mention it? It says balances aren't capped at in-network amounts — meaning the number keeps growing — but the threshold comparison for in-network claims would still trigger.
So yes: after family OOP balance crosses 14000, all subsequent in-network covered services are paid at 100% by the plan (no member cost share).
Family OOP crossed 14000 at line 13 (14445.30). So lines 19, 20, 21, 22, 24, 25 (in-network) → member responsibility 0.00, plan pays 100% of allowed, deductible_applied 0 (deductible long met), coinsurance 0.
Wait, but check line 20: routine immunisation, in-network — preventive! In-network preventive: paid 100%, no cost share, no accumulator movement. Claim 20 original: allowed 1243.12, member resp 0, plan 1243.12. Then line 23 adjustment: allowed corrected to 745.87. Re-adjudicate: still preventive in-network → member resp 0, plan paid 745.87. No accumulator changes either way (no credits generated originally, so unwinding changes nothing).
Hmm wait — is routine immunisation preventive? "Routine immunisation, in-network" — yes, immunizations are preventive services required to be covered without cost share. The plan says "In-network preventive services required to be covered without cost share are paid at 100% of the allowed amount." Routine immunisation is plainly in that category. Also claim 11 was "Annual wellness visit" OON — flagged OON preventive → subject to OON ded/coins. Claim 13 "Screening colonoscopy" OON — same treatment. The fact that the ledger explicitly marks OON preventive services implies the in-network immunisation is the preventive freebie. Also its billed/allowed amounts are large, perhaps to tempt treating it as non-preventive, or to tempt OOPM interactions. Given family OOP already > 14000 by then, even if it weren't preventive it would be 100% plan paid. Either way member resp 0.
Let me continue the ledger.
Line 19 — Claim 19 — B — in-network urgent care — allowed 220.46.
Deductible applied 0. Coinsurance: family OOP balance 17909.13 ≥ 14000 → plan pays 100%. Member resp 0.00; plan 220.46. Coinsurance amount 0.00. Copay 0.00 (no copays in plan).
Accumulators unchanged.
Actually wait — I should double-check the OOPM mechanics: is the individual OOPM embedded, such that B's cost share is limited by B's own 7000, and the family 14000 caps everyone? B's own OOP = 2039.77, under 7000. Family = 17909.13 > 14000. Under standard embedded OOPM, once family OOPM met, no member pays. So member resp 0. Yes.
Line 20 — Claim 20 — A — in-network routine immunisation — allowed 1243.12.
Preventive in-network: member resp 0, plan 1243.12, no accumulator movement. deductible_applied 0, coinsurance 0, copay 0.
(Even if not preventive, family OOP met → same result.)
Line 21 — Claim 21 — C — in-network ED — allowed 3516.29.
Family OOP met → member resp 0; plan 3516.29.
Line 22 — Claim 22 — E — in-network inpatient — allowed 12475.02.
Family OOP met → member resp 0; plan 12475.02.
Line 23 — ADJUSTMENT to Claim 20 — allowed corrected to 745.87.
Claim 20 originally generated no credits (member resp 0, ded applied 0). Unwind: nothing changes. Re-adjudicate: preventive in-network → member resp 0.00, plan paid 745.87, deductible_applied 0.00.
Claim 20 final components: member_responsibility 0.00, plan_paid 745.87, deductible_applied 0.00, copay 0.00, coinsurance 0.00.
Line 24 — Claim 24 — D — in-network PCP visit — allowed 201.22.
Family OOP met → member resp 0; plan 201.22.
Line 25 — Claim 25 — D — in-network PT course — allowed 1508.35.
Family OOP met → member resp 0; plan 1508.35.
Now ending accumulators.
Member A:
- Deductible credits: line 1: 74.87; line 15: 2331.25. Total 2406.12. (Claim 6 void had ded 0 anyway; claim 20 no ded.)
- OOP: line 1: 74.87; line 4: 25.53; line 5: 354.52; line 6: 91.19 → voided (line 16) → remove 91.19; line 15: 2331.25. Total: 74.87 + 25.53 + 354.52 + 2331.25 = 2786.17.
Check: 74.87+25.53 = 100.40; +354.52 = 454.92; +2331.25 = 2786.17. Yes.
Member B:
- Ded: line 12: 30.19. Total 30.19.
- OOP: line 7: 784.55; line 9: 1225.03; line 12: 30.19; line 19: 0. Total 2039.77.
Member C:
- Ded: line 2: 6400.00. Total 6400.00.
- OOP: line 2: 8193.58; line 3: 387.20 → voided; line 18: 237.28; line 21: 0. Total: 8193.58 + 237.28 = 8430.86.
Member D:
- Ded: line 11: 664.62; line 13: 716.51. Total 1381.13.
- OOP: line 8: 675.06; line 10: 1222.45; line 11: 664.62; line 13: 716.51; lines 24, 25: 0. Total: 675.06+1222.45 = 1897.51; +664.62 = 2562.13; +716.51 = 3278.64.
Member E:
- Ded: line 17: 1373.69.
- OOP: line 17: 1373.69; line 22: 0. Total 1373.69.
Family:
- Ded: A 2406.12 + B 30.19 + C 6400.00 + D 1381.13 + E 1373.69 = let's sum: 2406.12+30.19 = 2436.31; +6400 = 8836.31; +1381.13 = 10217.44; +1373.69 = 11591.13. Matches line-by-line.
- OOP: A 2786.17 + B 2039.77 + C 8430.86 + D 3278.64 + E 1373.69 = 2786.17+2039.77 = 4825.94; +8430.86 = 13256.80; +3278.64 = 16535.44; +1373.69 = 17909.13. Matches.
Now the claim components:
Claim 19 (B, in-network urgent care, allowed 220.46): family OOPM met → member_responsibility 0.00, plan_paid 220.46, deductible_applied 0.00, copay 0.00, coinsurance 0.00.
Claim 20 (adjusted, allowed 745.87, in-network preventive): member_responsibility 0.00, plan_paid 745.87, dedujson{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 8,494 tokens
We need solve accurately. We need step-by-step ledger with aggregate deductible. Need understand plan document nuances. Need report claims 19,20,25 adjusted claim 20. Ending accumulators.
We need parse rules carefully:
- Aggregate in-network deductible family 6400, no individual deductible. "Under aggregate structure no member reaches coinsurance until family amount met." Deductible_applied for in-network is family remainder alone.
- Out-of-network threshold individual 6400, measured against member's single deductible balance (which includes in-network and OON credits). Family in-network amounts do not limit OON claims. Credits accumulate to member balance and family balance.
- OOPM: in-network individual 7000, family 14000; OON individual 14000. For OON claims measured against OON individual threshold only; family in-network amounts don't limit OON. But credits accumulate to member and family OOP balance. Once member reaches OOPM plan pays 100%.
- Coinsurance IN 10%, OON 40%. No copays.
- Preventive in-network free; OON preventive subject to OON deductible/coins.
- Adjustment: unwind claim credits from accumulators and re-adjudicate against accumulators as they stand at adjustment.
- Void: unwind and post nothing.
- Ending accumulators report totals.
Need adjudicate each line. We need track member deductible balance, family deductible balance; member OOP balance, family OOP balance. For each claim:
- deductible_applied = min(allowed, applicable remainder). For in-network aggregate: family deductible remainder (6400 - family deductible balance). For OON: OON individual remainder (6400 - member deductible balance). It can be limited also by allowed.
- Then coinsurance applies to allowed - deductible_applied at rate. But also need check OOPM. Member responsibility = deductible_applied + coinsurance, possibly capped at OOPM threshold (in-network individual threshold for in-network; OON individual threshold for OON). Because family OOPM is aggregate? Plan says OOPM individual and family. Likely in-network claims subject to both individual and family thresholds? The accumulator addendum says "Once the applicable threshold is met" and for OOP: in-network the smaller of member's individual remainder and family remainder? Actually the ACCUMULATORS section only explicitly describes deductible_applied remainder. For OOP, plan document lists individual and family; we should infer both limit in-network: memberresponsibility capped by member's remaining individual OOP and family OOP remainder. Aggregate deductible is explicitly only family. For OOP most family plans have embedded individual OOP within family; even if deductible aggregate, OOPM often has individual and family. Need apply both: member responsibility limited by min(member individual OOP remainder, family OOP remainder). But final results maybe not affected? Need check. For OON claims thresholds individual 14000 only and family amounts don't limit. But credits still accumulate to family OOP balance. We'll need see if family OOP 14000 reached; yes likely, and affects subsequent in-network claims. Need careful.
Let's process all.
Initial all zero.
Thresholds:
Deductible:
- in-network claims: family total remainder from 6400.
- OON claims: member's deductible balance vs 6400.
OOP:
- in-network: min(member OOP balance remaining to 7000, family OOP balance remaining to 14000).
- OON: member OOP balance remaining to 14000 (not family).
Need know how member OOP balance and family OOP balance incremented: by member_responsibility. Even for OON, both. For in-network maybe both.
Let's do exact arithmetic with cents. Round half up at end of calc. Coinsurance percentages on allowed minus deductible. Need decide when rounding: "Round half up to the cent at the end of a calculation, not at each intermediate step." For each claim, coinsurance = (allowed - deductible)*rate rounded to cent. Member responsibility = deductible_applied + coinsurance, possibly OOP-capped. Plan paid = allowed - member_resp. We'll round coinsurance half up. Since amounts decimals, percentages may produce 3 decimals. Use exact Decimal arithmetic mentally or systematically.
Let's define helper for 10%: coins = (allowed - ded)*0.10; for 40%: *0.40. Terminating decimals. Need handle half up.
We'll process.
Line1 Claim1 A IN allowed 74.87. Family ded remaining 6400. deductible_applied = 74.87. member_resp =74.87, plan_paid 0.00. A ded balance 74.87; family ded 74.87. A OOP 74.87; family OOP 74.87.
Line2 Claim2 C OON inpatient allowed 10883.95. C ded bal 0, OON individual remaining 6400. deductible_applied=6400. Remainder after ded =4483.95; coins 40%=1793.58 (4483.95*0.4 =1793.58 exact? 4483.95*4=17935.8 /10 =1793.58 yes). member_resp =6400+1793.58=8193.58. C OOP balance 8193.58 (OON individual threshold 14000, room enough). family OOP 74.87+8193.58=8268.45. plan paid=10883.95-8193.58=2690.37. C ded balance 6400 (met); family ded 74.87+6400=6474.87. Note family ded balance surpasses in-network family threshold due OON claim—okay not capped.
Line3 Claim3 C OON lab allowed 967.99. C ded balance 6400, OON threshold met, deductible_applied=0.00. coins 40% of 967.99 = 387.196 -> 387.20 half up. member_resp 387.20. C OOP 8580.78. family OOP 8268.45+387.20=8655.65. plan paid 580.79. (Later voided.)
Line4 Claim4 A IN urgent allowed 255.34. Family deductible balance currently 6474.87 (already >6400), so remainder 0. deductible=0. Coins 10% of 255.34=25.534 ->25.53. member_resp=25.53. Check A OOP ind rem: A had 74.87, family 8655.65; okay. A OOP 100.40; family OOP 8681.18. Plan paid 229.81.
Line5 Claim5 A IN ED allowed 3545.18. Family ded met, ded 0. Coins 10%=354.518 ->354.52. member_resp 354.52. A OOP 100.40+354.52=454.92. family OOP 8681.18+354.52=9035.70. plan paid 3190.66.
Line6 Claim6 A IN allergy allowed 911.89. ded 0. coins 91.189 ->91.19. member_resp 91.19. A OOP 546.11; family 9126.89. plan paid 820.70. (Later voided.)
Line7 Claim7 B IN ambulatory surgery allowed 7845.50. ded 0 (family ded met). coins 10%=784.55 exact (7845.50*0.1=784.55). member_resp 784.55. B OOP 784.55. family OOP 9126.89+784.55=9911.44. plan paid 7060.95.
Line8 Claim8 D IN surgery allowed 6750.63. ded 0. coins=675.063 ->675.06. member_resp 675.06. D OOP 675.06; family 9911.44+675.06=10586.50. plan paid 6075.57.
Line9 Claim9 B IN inpatient allowed 12250.27. ded 0. coins=1225.027 ->1225.03. member_resp 1225.03. B OOP 784.55+1225.03=2009.58; family 10586.50+1225.03=11811.53. plan paid 11025.24.
Line10 Claim10 D IN inpatient allowed 12224.51. ded 0. coins=1222.451 ->1222.45. member_resp 1222.45. D OOP 675.06+1222.45=1897.51. family 11811.53+1222.45=13033.98. plan paid 11002.06.
Line11 Claim11 D OON annual wellness (preventive OON subject). Allowed 664.62. D ded member balance so far? D had in-network claims, deductible_applied 0 both, so D ded balance 0. OON individual remainder 6400. deductible=664.62. coins on remainder 0. member_resp=664.62. D OOP 1897.51+664.62=2562.13. family OOP 13033.98+664.62=13698.60. D ded balance 664.62; family ded balance currently after line 2 was 6474.87 + line? In-network lines after had ded 0. So family ded 6474.87 + 664.62=7139.49. Plan paid 0.
Line12 Claim12 B OON pharmacy allowed 30.19. B ded balance currently 0 (IN claims ded 0). deductible_applied=30.19 (OON remainder 6400). member_resp=30.19. B ded balance 30.19; family ded 7139.49+30.19=7169.68. B OOP 2009.58+30.19=2039.77; family OOP 13698.60+30.19=13728.79. plan paid 0.
Line13 Claim13 D OON screening colonoscopy (preventive OON) allowed 716.51. D ded balance 664.62, OON remainder=5735.38. deductible=716.51. member_resp=716.51. D ded balance=1381.13; family ded 7169.68+716.51=7886.19. D OOP=2562.13+716.51=3278.64. Family OOP=13728.79+716.51=14445.30. Note family OOP now exceeds family in-network max 14000 because OON claims can push past; allowed per addendum. Important: family OOP >14000. This means for subsequent in-network claims, family remainder is zero, so member_resp maybe 0 even if individual OOP remains. Need determine. Since family OOP is part of thresholds for in-network, yes subsequent IN claims should be plan paid 100. But addendum says "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This indeed means an OON claim can push family OOP past family in-network amount and then subsequent in-network claims may pay 100 because family OOP met. They also say "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." So for in-network claims, family amount does limit. Need apply.
Line14 VOID Claim3 C. Remove claim3: deductible_applied 0, member_resp 387.20. C OOP reduce 387.20: from 8580.78 to 8193.58. Family OOP reduce 387.20 from 14445.30 to 14058.10. C ded unchanged (claim3 ded 0) 6400; family ded unchanged 7886.19. Still family OOP >14000.
Line15 Claim15 A OON endoscopy allowed 2331.25. A ded balance so far: Claim1 ded 74.87; Claims4/5/6 ded 0; so A ded=74.87. OON individual remainder =6400-74.87=6325.13. So deductible_applied=2331.25. coins 40% on remainder 0 =0. member_resp 2331.25. A ded balance=2406.12; family ded=7886.19+2331.25=10217.44. A OOP before void: A OOP 546.11 (claim6 still credited at this point? Wait line14 only voided Claim3; claim6 still credited until line16. A OOP 546.11). Add 2331.25 =2877.36. Family OOP 14058.10+2331.25=16389.35. Plan paid 0.
Line16 VOID Claim6 A. Claim6 ded 0, member_resp 91.19. Remove from A OOP: 2877.36-91.19=2786.17. Family OOP 16389.35-91.19=16298.16. Deductible unaffected. A ded 2406.12; family ded 10217.44.
Line17 Claim17 E OON PT allowed 1373.69. E ded balance 0. OON rem 6400. deductible=1373.69. member_resp=1373.69. E OOP=1373.69; E ded=1373.69; family ded=10217.44+1373.69=11591.13; family OOP=16298.16+1373.69=17671.85. plan paid 0.
Line18 Claim18 C OON lab allowed 593.21. C ded balance after line2 =6400 (claim3 void didn't affect ded), so OON ded remainder 0. deductible=0. coins 40%=237.284 ->237.28. Check C OOP=8193.58; OON individual OOP threshold 14000, plenty. member_resp=237.28. C OOP=8430.86. family OOP=17671.85+237.28=17909.13. plan paid=355.93. Family ded unchanged 11591.13; C ded 6400.
Line19 Claim19 B IN urgent care allowed 220.46. At this point family ded=11591.13 > family threshold so ded 0. Family OOP=17909.13 >14000, B OOP=2039.77. For in-network, family OOP remainder = max(14000-17909.13,0)=0, so member responsibility=0.00, plan paid=220.46, coinsurance 0.00. Need confirm. If OOP family threshold not limiting in-network? It should. So claim19 all zero responsibility. This is likely why asked claim19. The OON spending pushed family OOP over 14000; in-network claim pays 100%. We must be certain about interpretation. Addendum explicitly says family OOP balances can pass family amounts due OON claims and aren't capped. So yes. Claim19 member resp 0, ded 0, coins 0, plan paid 220.46.
Line20 Claim20 A IN routine immunisation. This is preventive in-network, likely paid 100%, no cost share, no accumulator. "Routine immunisation" is preventive. So original Claim20 allowed 1243.12: member_resp 0, plan_paid 1243.12, ded 0, no accumulator. Later adjusted allowed downward to 745.87. Preventive in-network still no cost share. Adjustment unwinds (nothing) and re-adjudicates at corrected allowed: plan_paid 745.87, member_resp 0.00, ded 0.00, copay 0, coins 0. No accumulator impact. Family/member balances unchanged. This is why report adjusted components. Need classify routine immunisation as preventive. Yes.
Line21 Claim21 C IN ED allowed 3516.29. Family ded met. Family OOP currently still 17909.13 (claim19/20 no cost share). >14000. So in-network member_resp 0 if family OOP limits. Plan paid 3516.29. C OOP unchanged 8430.86; family OOP unchanged. deductible 0.
Line22 Claim22 E IN inpatient allowed 12475.02. Family OOP >14000, so member resp 0; plan paid full. E OOP remains 1373.69; family OOP unchanged.
Line23 ADJUST Claim20. As above, remove original credits (none) and repost at allowed 745.87, plan paid 745.87, member resp 0. No accumulator.
Line24 Claim24 D IN primary care allowed 201.22. Family OOP still >14000. member responsibility 0, plan paid 201.22. D ded 0. accumulators unchanged.
Line25 Claim25 D IN PT course allowed 1508.35. member_resp 0, plan paid 1508.35, ded 0, coins 0, copay 0. accumulators unchanged.
Ending accumulators as after line18 because later no cost share:
A:
- Deductible balance: claims affecting: claim1 ded 74.87; claim4,5 ded 0; claim6 ded0 voided; claim15 ded 2331.25; claim20 preventive 0; adjustment 0. So A ded =74.87+2331.25=2406.12.
- OOP balance: claim1 74.87 + claim4 25.53 + claim5 354.52 + claim6 91.19 - void 91.19 + claim15 2331.25 + claim20 0 =? 74.87+25.53=100.40; +354.52=454.92; +2331.25=2786.17. Yes A OOP 2786.17.
B:
- ded: Claim7/9/19 IN ded 0; Claim12 OON ded 30.19. Total 30.19.
- OOP: claim7 784.55 + claim9 1225.03 + claim12 30.19 + claim19 0 =2039.77. Yes.
C:
- ded: claim2 6400, claim3 0 void, claim18 0, claim21 0 ->6400.00.
- OOP: claim2 8193.58 + claim3 387.20 - void 387.20 + claim18 237.28 + claim21 0 =8430.86. Good.
D:
- ded: claim8/10 IN ded0; claim11 OON 664.62; claim13 OON 716.51; claims24/25 IN ded0=1381.13.
- OOP: claim8 675.06 + claim10 1222.45 + claim11 664.62 + claim13 716.51 + claim24/25 0 =3278.64. Check sum: 675.06+1222.45=1897.51; +664.62=2562.13; +716.51=3278.64.
E:
- ded: claim17 OON 1373.69; claim22 IN 0 =>1373.69.
- OOP: claim17 1373.69; claim22 0 =>1373.69.
Family:
- ded total sum member ded balances: A 2406.12 + B 30.19 + C 6400 + D 1381.13 + E 1373.69 =? 2406.12+30.19=2436.31; +6400=8836.31; +1381.13=10217.44; +1373.69=11591.13. Yes.
- family OOP sum member OOP: A 2786.17 + B 2039.77 + C 8430.86 + D 3278.64 + E 1373.69 =? 2786.17+2039.77=4825.94; +8430.86=13256.80; +3278.64=16535.44; +1373.69=17909.13. Yes.
Claims requested:
Claim19 (as line19 original, not adjusted/voided): member_resp 0.00 plan_paid 220.46 ded 0.00 copay 0.00 coins 0.00.
Claim20 adjusted: allowed corrected 745.87. member_resp 0.00 plan_paid 745.87 ded 0 copay0 coins0.
Claim25: member_resp0 plan_paid1508.35 ded0 copay0 coins0.
Need consider whether family OOP max indeed makes claims 19/21/22/24/25 zero. If not, coins would be small and accumulators differ. Let's scrutinize plan language:
Out-of-pocket maximum
Individual (in-network) 7000
Family (in-network) 14000
Individual (out-of-network) 14000
Once a member reaches the out-of-pocket maximum plan pays 100%.
In accumulator addendum:
"A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts.
Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
This is included to clarify exactly that OON can push family OOP beyond family threshold. And for subsequent IN, family amount (14000) is met (balance beyond), so no cost share. It also mentions member's balance past in-network individual amount means subsequent in-network individual threshold met. So yes.
However, one nuance: Under aggregate deductible, family deductible reached after claim2 (family ded balance 6474.87) because OON claims count towards family balance. That makes later IN ded 0. We've done.
Another nuance: Claim2 member responsibility maybe should be capped by member OOP in-network individual 7000? For OON claim, use OON individual 14000 only, so 8193.58 okay. Family OOP not limit OON per addendum. Good.
Potential issue: When claim11 D OON annual wellness: D had prior IN claims with member responsibility 675.06+1222.45=1897.51 but deductible balance 0 because family ded already met by C's OON before D's IN claims. Yes OON individual threshold measured against member's single deductible balance; D's IN claims contributed no deductible because family aggregate already satisfied, but still member's own deductible balance is 0. Does that matter? "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 in-network deductible credits (when generated) accumulate to member balance. For D, claims 8/10 had deductible_applied 0 because family threshold met, so D balance 0. So OON claim11 pays deductible. Correct.
Likewise B claim12 OON pays deductible even though family ded met. Good.
A claim15 OON pays deductible because A ded balance only 74.87 from claim1; other IN ded 0. Claim6 void later no ded. Correct.
E claim17 OON pays deductible from zero. Correct.
The family OOP threshold crossing occurs at line13, before claim19 etc. Actually family OOP after line10 13033.98. Claim11 OON D adds 664.62 ->13698.60. Claim12 OON B adds 30.19 ->13728.79. Claim13 adds 716.51 ->14445.30. So claim13 itself is OON and not capped by family threshold; even though it crosses family OOP, measured only against D's OON individual threshold (14000), so full member_resp. This pushes family OOP over. Good.
Claim15 A OON at line15 also adds full member responsibility despite family OOP already over, because OON not limited by family. Claim17,18 also OON add. Claim18 coins for C because C OON deductible met; family OOP not limiting OON; correct.
Now line19 in-network zero due family OOP. Good.
But wait: For in-network claim, the applicable OOP threshold might be min(member individual remainder and family remainder), like embedded. If family balance already over, all IN zero. If the task designers expect this yes.
Let's validate all arithmetic and rounding.
Detailed table:
Claim1 allowed 74.87 ded 74.87 mem 74.87 plan0.
Claim2 allowed10883.95 ded6400 coins1793.58 mem8193.58 plan2690.37.
Claim3 allowed967.99 ded0 coins 387.196 round 387.20 mem 387.20 plan580.79. Voided -> components zero if asked, not here.
Claim4 allowed255.34 ded0 coins25.53 mem25.53 plan229.81.
Claim5 allowed3545.18 ded0 coins354.52 plan3190.66.
Claim6 allowed911.89 coins91.19 plan820.70 void.
Claim7 7845.50 coins784.55 plan7060.95.
Claim8 6750.63 coins675.06 plan6075.57.
Claim9 12250.27 coins1225.03 plan11025.24.
Claim10 12224.51 coins1222.45 plan11002.06.
Claim11 664.62 ded full plan0.
Claim12 30.19 ded full plan0.
Claim13 716.51 ded full plan0.
Claim15 2331.25 ded full plan0.
Claim17 1373.69 ded full plan0.
Claim18 593.21 coins237.28 plan355.93.
Claim19 allowed220.46, fam OOP met -> plan220.46.
Claim20 preventive -> plan originally1243.12 adjusted745.87.
Claim21 plan3516.29.
Claim22 plan12475.02.
Claim24 plan201.22.
Claim25 plan1508.35.
A accumulator:
Ded: 74.87 + 2331.25 = 2406.12.
OOP: 74.87+25.53+354.52+91.19-91.19+2331.25 =2786.17.
B ded30.19, oop 784.55+1225.03+30.19=2039.77.
C ded 6400. Claim3 void didn't affect ded, but if claim3 posted ded 0. Yes. OOP:8193.58+237.28=8430.86.
D ded 664.62+716.51=1381.13. OOP:675.06+1222.45+664.62+716.51=3278.64.
E ded1373.69, oop1373.69.
Family totals as above.
Need output exactly one fenced JSON block, no other. Key names exactly. Need numeric values? Should we format as numbers with two decimal places. JSON numbers can include trailing zeros; write 0.00. JSON parser accepts. Good.
Let's ensure all required keys:
claim_19_member_responsibility, claim_19_plan_paid, claim_19_deductible_applied, claim_19_copay_amount, cjson{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Gemini 2.5 Pro · Google139.1s · 17,187 out | 104.1s · 13,875 out | 121.9s · 15,846 out
Reasoning · 16,657 tokens
Here's my thought process for handling this claim adjudication scenario. I'll walk through how I approached it, from understanding the plan details to processing each claim and reconciling the accumulator balances.
**Initial Understanding and Setup**
My first step was to internalize the plan specifics: "Trinity HDHP 3200" for the year 2026. The key here is the "AGGREGATE" structure for the family deductible. This means the plan doesn't start paying any coinsurance for *any* member until the *total* family deductible of $6400.00 is met. The individual deductible of $3200.00 for in-network services is effectively superseded by this aggregate family deductible for in-network claims. I also noted that individual deductibles accumulate both in-network and out-of-network credits, and the out-of-network deductibles are higher.
I carefully noted the out-of-pocket maximums (OOPM), both individual and family, and the coinsurance percentages for in-network (10% member) and out-of-network (40% member). The rules for preventive care and the distinctions between "ADJUSTMENT" and "VOID" were also crucial.
Then, I meticulously set up the initial accumulator balances for each of the five family members (A, B, C, D, E) and the family as a whole. All start at $0.00 for both deductible and OOPM.
**Claim-by-Claim Processing Strategy**
My core strategy was to process each claim chronologically, applying the plan rules sequentially. For each claim, I needed to:
1. **Determine the Service Type:** Is it In-Network (IN) or Out-of-Network (OON)? Is it preventive?
2. **Apply Deductible:**
* For IN services, I first checked if the *family* deductible was met. If not, I applied the remaining family deductible balance to the claim, crediting both the individual member's and the family's deductible accumulators. If the family deductible was met, no deductible was applied to this claim.
* For OON services, I checked the *individual* member's deductible accumulator. I applied the remaining deductible amount up to the individual OON deductible limit ($6400.00), crediting the individual's deductible and OOPM, and the family's deductible and OOPM.
3. **Apply Cost Share (Coinsurance):** After deductible application, any remaining allowed amount is subject to coinsurance.
* For IN services (after family deductible met): 10% member / 90% plan.
* For OON services (after individual deductible met): 40% member / 60% plan.
4. **Check Out-of-Pocket Maximums (OOPM):** This was a critical and sometimes tricky step.
* I added the member's responsibility (deductible + coinsurance for that claim) to their *individual* OOPM accumulator.
* I also added this member responsibility to the *family* OOPM accumulator.
* Crucially, I had to determine if the service was IN or OON when considering OOPM limits. For IN services, the IN individual ($7000) and IN family ($14000) OOPM limits are paramount. If a member's individual OOPM accumulator or the family's OOPM accumulator (depending on the service type and context) had already exceeded the relevant IN OOPM threshold *before* processing the current claim, the plan would pay 100% of the allowed amount for that IN-network service. Similarly, for OON services, the OON individual ($14000) OOPM limit applies.
* I had to be very careful about how OON claims could push the *accumulators* past the IN OOPM thresholds, and then how subsequent IN claims would be evaluated against those met thresholds. The rule "Once a member reaches the out-of-pocket maximum the plan pays 100%..." was key.
5. **Calculate Member Responsibility (MR) and Plan Paid (PP):** MR is the sum of deductible and coinsurance applied to the member. PP is the allowed amount minus MR.
6. **Update Accumulators:** All calculated amounts affecting deductibles and OOPMs were added to the respective individual and family accumulators.
7. **Document Intermediate States:** For VOID or ADJUSTMENT claims, I made a note of the "deductible applied" and "member responsibility" from the original processing so I could correctly unwind them.
**Detailed Walkthrough and Refinements**
* **Claims 1-13:** This was a straightforward application of the rules. I diligently tracked the accumulators. I specifically noted the OON services for C and D, ensuring their individual deductibles were applied first, followed by OON coinsurance. I also noted when the family IN deductible was met, and how that shifted subsequent IN claims to coinsurance. The aggregate nature of the family deductible was evident here.
* **Claims 14 & 16 (VOIDs):** This required careful unwinding. I took the stored "deductible applied" and "member responsibility" from the original processing of Claims 3 and 6 and subtracted them from the current accumulator balances. This effectively reversed the impact of those claims.
* **Claims 15 & 17-18:** More OON claims, again applying individual deductibles and then coinsurance where applicable. I noticed the family OOPM accumulator starting to creep up significantly due to OON claims.
* **Claim 19 (Crucial Re-evaluation):** This is where I had to pause and re-read the OOPM rules carefully. Before processing Claim 19, the **family OOPM accumulator was $17,909.13**. The IN-network family OOPM limit is **$14,000.00**. Since the accumulator had already exceeded the limit, any *in-network* service for *any* family member should be paid at 100% by the plan, regardless of the individual member's OOPM status. This corrected my initial calculation for Claim 19, making the member responsibility $0.00 and the plan paid the full allowed amount.
* **Claims 20-22 (Post-OOPM Met):** Following the realization from Claim 19, I applied the 100% plan payment logic for all subsequent in-network claims (21, 22, 24, 25) as the family IN OOPM was met. This meant no further member responsibility or accumulator updates for those specific claims. The adjustment to Claim 20 also followed this logic.
* **Accumulator Tracking:** Throughout this process, I maintained a running tally of all individual and family deductible and OOPM accumulators. The VOIDs meant I had to go back and re-adjust based on those subtractions. The key insight was that the OOPM thresholds (especially the IN family OOPM) acted as "tripwires." Once tripped, subsequent IN services were fully covered.
**Final Calculations and Reporting**
After processing all claims and adjustments, I reviewed the final state of the accumulators. Because claims 19 through 25 resulted in no member responsibility (due to the family OOPM being met), the accumulator balances from after Claim 18 remained unchanged.
The specific outputs requested were:
* **Claim 19 Components:**
* My initial processing (before the OOPM realization) showed MR of $22.05 and PP of $198.41.
* However, my revised processing, recognizing the met family OOPM, correctly determined **MR = $0.00** and **PP = $220.46**. Deductible applied was $0.00, and coinsurance was $0.00.
* **Claim 20 Components (Adjusted):**
* The adjustment processed the claim as preventive, with 100% plan coverage. **MR = $0.00**, **PP = $745.87**. Deductible applied was $0.00, and coinsurance was $0.00.
* **Claim 25 Components:**
* This was an IN service after the family OOPM was met. **MR = $0.00**, **PP = $1508.35**. Deductible applied was $0.00, and coinsurance was $0.00.
* **Final Accumulator Balances:**
* These were derived from the state after Claim 18, as claims 19-25 did not add to member responsibility.
* Member A: Deductible $2406.12, OOPM $2786.17
* Member B: Deductible $30.19, OOPM $2039.77
* Member C: Deductible $6400.00, OOPM $8430.86
* Member D: Deductible $1381.13, OOPM $3278.64
* Member E: Deductible $1373.69, OOPM $1373.69
* Family Deductible: $11591.13
* Family OOPM: $17909.13
This step-by-step, iterative process, with careful attention to the interaction of IN/OON rules, aggregate deductibles, and especially the OOPM thresholds, allowed me to arrive at the final adjudication. The key was the constant cross-referencing of the current claim's details against the accumulated balances and the plan's limits.json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 13,345 tokens
Here's a summary of my thought process as I worked through this claims adjudication scenario.
My primary objective is to accurately process a ledger of 25 claims for a family of five, meticulously tracking each member's and the family's deductible and out-of-pocket maximum (OOPM) accumulators. I need to determine the member responsibility and plan payment for each claim, applying the specific plan rules of the Trinity HDHP 3200 for the 2026 plan year. Ultimately, I'm tasked with providing the adjudicated components for claims 19, 20, and 25, along with the final accumulator balances for all individuals and the family unit.
First, I meticulously reviewed the plan details. The key differentiators here are:
* **Aggregate Family Deductible (In-Network):** This is crucial. No coinsurance applies for any member until the *total* family credits hit the $6,400 family deductible. There's no separate individual in-network deductible; it's all aggregated at the family level.
* **Deductible Accumulation:** Both in-network and out-of-network (OON) deductible credits contribute to a single balance.
* **OOPM Structure:** Individual OOPMs are $7,000 (in-network) and $14,000 (out-of-network). The family OOPM of $14,000 is specifically for *in-network* services. Once an individual hits their OOPM, the plan covers 100% of allowed costs.
* **Cost Share:** 10% member/90% plan for in-network coinsurance, and 40% member/60% plan for out-of-network coinsurance. No copays.
* **Preventive Care:** In-network preventive services are 100% covered, no cost share, and don't impact accumulators. OON preventive services *are* subject to deductible and coinsurance.
* **Adjustments and Voids:** I understand that an "ADJUSTMENT" unwinds credits and re-adjudicates against current accumulators, while a "VOID" simply unwinds credits, effectively zeroing out the original claim.
I started with a clean slate: all individual and family accumulators set to zero.
My process then became a sequential, line-by-line analysis of the claims. For each claim, I performed the following:
1. **Identify Member and Network:** Determine who the claim is for and whether it's in-network (IN) or out-of-network (OON).
2. **Determine Applicable Deductible:** Based on the network, I identified whether the claim applied to the individual OON deductible (for OON claims) or the family aggregate deductible (for IN claims).
3. **Calculate Deductible Applied:** I compared the allowed amount against the remaining deductible balance for the relevant accumulator. For IN, it's the family deductible remainder; for OON, it's the individual OON deductible remainder for that member.
4. **Calculate Coinsurance:** If the deductible was met, I calculated the coinsurance based on the remaining allowed amount and the plan's coinsurance percentages.
5. **Determine Member Responsibility (MR):** This is the sum of any applicable deductible amount and the member's coinsurance share.
6. **Determine Plan Paid Amount:** This is the allowed amount minus the member responsibility.
7. **Update Accumulators:**
* **Deductible:** Any `deductible_applied` amount was added to the member's and family's deductible accumulators.
* **OOPM:** The member's responsibility (`MR`) was added to the member's and family's OOPM accumulators. I paid close attention to the family OOPM limit for IN-NETWORK claims. If the family OOPM had already been met, subsequent IN-NETWORK claims were paid at 100% by the plan. A critical point was realizing the family OOPM does *not* limit OON claims, as explicitly stated.
8. **Handle Adjustments and Voids:** When I encountered these, I first went back to the accumulator state *just before* the affected claim. I then 'unwound' the contributions of the original claim from those accumulators. For adjustments, I then re-adjudicated the claim using the current allowed amount and the updated accumulator balances.
**Specific points of note during processing:**
* **Claim 2 (C, OON):** This claim significantly contributed to both the individual C's OON deductible and the family's aggregate deductible. It also pushed the family's OOPM close to its limit.
* **Claim 3 (C, OON):** This was a straightforward OON claim after the deductible was met. I made a note that this claim would later be voided.
* **Claims 4-10 (IN services):** These claims mainly contributed to the family's OOPM as the family deductible was already met. I watched the family OOPM accumulator closely.
* **Claim 11 & 13 (D, OON Preventive):** These were OON preventive services. While deductible applied, the key was that the family OOPM didn't cap these.
* **Claim 13 Re-evaluation:** I initially thought the family OOPM would cap the OON claim's member responsibility, but rereading the rules clarified that the family OOPM is strictly for *in-network* services. This was a crucial correction.
* **Voiding Claims 3 and 6:** These required careful unwinding of their specific contributions from the accumulators as they stood *after* subsequent claims had been processed. This meant I had to keep a running tally of accumulator states.
* **Claims 19, 20, 25:** These were the target claims for detailed output. For claim 19, I saw that the family IN OOPM had been met, so it was paid at 100% by the plan. Claim 20, initially processed as preventive, was later adjusted. The adjustment meant re-adjudicating it as preventive *again* at the new allowed amount, still resulting in 100% plan payment and no accumulator impact. Claim 25 was another IN claim occurring after the family IN OOPM was met, thus paid at 100%.
Throughout this process, I ensured that all decimal calculations were carried to two places and that the logic for applying deductibles, coinsurance, and OOPM limits was strictly followed, especially the distinction between IN and OON processing and the impact of voids and adjustments. The aggregate nature of the family deductible and the specific capping rules for the family OOPM were central to the correct adjudication.
This iterative process of calculating, updating, and re-checking against the plan rules allowed me to confidently arrive at the final accumulator balances and the specific components for the requested claims.
```json
{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
```json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 15,316 tokens
Here's my thought process as I've worked through this ledger of claims for your family. I'm breaking down each step, focusing on how the plan rules interact with the claims to determine member responsibility and how those costs accumulate against the deductibles and out-of-pocket maximums.
First, I meticulously reviewed the plan details provided. Understanding the "Trinity HDHP 3200" plan for the 2026 plan year is crucial.
* **Deductibles:** The key here is the *aggregate* family deductible of $6,400.00 for in-network services. This means the plan won't contribute anything to in-network claims until the *entire family* has collectively met this amount. For out-of-network (OON) services, there's an individual deductible threshold of $6,400.00. It's important to note that credits from both in-network and out-of-network claims accumulate towards a single member deductible balance and a single family deductible balance.
* **Out-of-Pocket Maximums (OOPM):** The in-network family OOPM is $14,000.00, and the individual OOPM is $7,000.00. The out-of-network individual OOPM is significantly higher at $14,000.00. A critical detail here is how OON claims interact with the family OOPM. The plan states that OON claims are measured against individual OON thresholds, and "family amounts, which are in-network amounts, do not limit an out-of-network claim." This implies that the family OOPM limit for *in-network* services might not cap OON costs, but it *does* cap subsequent in-network costs once it's met.
* **Cost Sharing:** For in-network services, it's a 10% member coinsurance after the deductible is met. For out-of-network, it jumps to 40% member coinsurance after the deductible. There are no copays.
* **Preventive Care:** In-network preventive care is fully covered and doesn't affect accumulators. Out-of-network preventive care, however, is subject to the OON deductible and coinsurance, which is a key point for some claims.
* **Adjustments/Voids:** I need to remember that voids simply remove credits without re-adjudication, while adjustments require unwinding previous credits and re-processing the claim with new values against the *current* accumulator balances.
With these rules in mind, I've established my tracking system. I'm using individual accumulators for each member (A, B, C, D, E) for both their deductible (`ded`) and OOPM (`oopm`), as well as overall family accumulators (`Fam_ded`, `Fam_oopm`). All start at zero.
Now, I'll walk through the claims chronologically, applying the plan logic and updating these accumulators as I go.
* **Claims 1-18:** I processed these claims sequentially, meticulously applying the deductible and coinsurance rules based on whether the service was in-network or out-of-network, and whether the family deductible had been met. I paid close attention to how out-of-network claims contributed to both individual and family accumulators. For instance, Claim 2, an inpatient admission for C out-of-network, was substantial. It applied the full $6,400.00 OON deductible for Member C and then 40% coinsurance on the remainder, significantly impacting C's and the family's accumulators. I also noted how Claim 13, an OON preventive colonoscopy for D, contributed to D's OON deductible. I also carefully handled the Voids for Claim 3 and Claim 6, ensuring I unwound the correct amounts from the accumulators *as they stood at that point in time*. The state of the accumulators after Claim 18 showed the family OOPM accumulator exceeding the $14,000.00 in-network limit, which is a critical condition for subsequent claims.
* **Claim 19 (Member B, Urgent Care, IN-network):** Here's where the family OOPM status becomes crucial. Since the family OOPM accumulator had already surpassed the $14,000.00 in-network family OOPM limit (it was at $17,909.13 after Claim 18), this in-network claim for B is covered at 100% by the plan. There's no member responsibility, and no deductible or OOPM amounts are applied to accumulators.
* **Claim 19 Components:**
* Member Responsibility: $0.00
* Plan Paid: $220.46
* Deductible Applied: $0.00
* Copay Amount: $0.00
* Coinsurance Amount: $0.00
* **Claim 20 (Member A, Routine Immunisation, IN-network):** This is an in-network preventive service. The plan covers 100% of these services, and they do not affect any accumulator balances.
* **Initial Claim 20 Components:**
* Member Responsibility: $0.00
* Plan Paid: $1,243.12
* Deductible Applied: $0.00
* Copay Amount: $0.00
* Coinsurance Amount: $0.00
* **Claims 21 & 22 (Members C & E, ED visit & Inpatient, IN-network):** Similar to Claim 19, these are in-network claims occurring after the family OOPM has been met. Therefore, they are covered at 100% by the plan with no member responsibility and no impact on accumulators.
* **Adjustment to Claim 20:** The original Claim 20 was processed as an in-network preventive service with $0.00 member responsibility. The adjustment changes the allowed amount but, importantly, the service remains in-network preventive care. No credits were applied to accumulators on the original claim, so there's nothing to unwind from the accumulators. The re-adjudicated claim continues to be covered at 100% with no member responsibility.
* **Final Claim 20 Components:**
* Member Responsibility: $0.00
* Plan Paid: $745.87
* Deductible Applied: $0.00
* Copay Amount: $0.00
* Coinsurance Amount: $0.00
* **Claims 24 & 25 (Member D, Primary Care & Physical Therapy, IN-network):** Again, these are in-network claims submitted after the family OOPM limit has been reached. They are therefore covered at 100% by the plan, resulting in $0.00 member responsibility and no changes to the accumulators.
* **Claim 25 Components:**
* Member Responsibility: $0.00
* Plan Paid: $1,508.35
* Deductible Applied: $0.00
* Copay Amount: $0.00
* Coinsurance Amount: $0.00
After processing all claims and adjustments, I've arrived at the final state of all the accumulators.
**Final State of Accumulators:**
* **Member A:**
* Deductible (`A_ded`): $2,406.12
* Out-of-Pocket Maximum (`A_oopm`): $2,786.17
* **Member B:**
* Deductible (`B_ded`): $30.19
* Out-of-Pocket Maximum (`B_oopm`): $2,039.77
* **Member C:**
* Deductible (`C_ded`): $6,400.00
* Out-of-Pocket Maximum (`C_oopm`): $8,430.86
* **Member D:**
* Deductible (`D_ded`): $1,381.13
* Out-of-Pocket Maximum (`D_oopm`): $3,278.64
* **Member E:**
* Deductible (`E_ded`): $1,373.69
* Out-of-Pocket Maximum (`E_oopm`): $1,373.69
* **Family Totals:**
* Family Deductible (`Fam_ded`): $11,591.13
* Family Out-of-Pocket Maximum (`Fam_oopm`): $17,909.13
This has been a detailed process, ensuring each claim's application of the specific plan rules, particularly the nuances of the aggregate family deductible and the out-of-network versus in-network cost-sharing and limits.json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100GLM-5.2 · Z.ai255.2s · 22,924 out | 571.3s · 26,548 out | 94.4s · 17,971 out
Reasoning · 21,869 tokens
Let me carefully work through this ledger step by step.
First, let me understand the plan:
- Aggregate deductible structure (family deductible must be met before any coinsurance)
- Individual in-network deductible: 3200.00
- Family in-network deductible: 6400.00
- Out-of-network individual deductible: 6400.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance
- In-network OOPM individual: 7000.00, family: 14000.00
- Out-of-network OOPM individual: 14000.00
- Coinsurance in-network: 10% member / 90% plan
- Coinsurance out-of-network: 40% member / 60% plan
- No copays
- Preventive services in-network: 100% covered, no cost share
- Out-of-network preventive: subject to OON deductible and coinsurance
Let me also understand the accumulator rules:
- Deductible_applied is the lesser of allowed amount and the room left under the deductible threshold
- For in-network: the family remainder (aggregate structure)
- For out-of-network: the OON individual remainder (6400.00), measured against the member's same single deductible balance
- OOPM is the running total of member_responsibility
- Out-of-network claims are measured against OON individual thresholds only; family amounts don't limit OON claims, but credits still accumulate to family balance
Wait, let me re-read the aggregate structure carefully.
"AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
So under aggregate, the family deductible of 6400.00 must be met before any coinsurance applies to any member.
But wait, there's also the out-of-network deductible of 6400.00 (individual). Let me re-read:
"Out-of-network (individual) ............ 6400.00
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."
And from the accumulators addendum:
"in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."
Hmm, this is interesting. So for in-network claims under aggregate structure, the deductible_applied is the family remainder alone.
For out-of-network claims, the deductible_applied is the out-of-network individual remainder (6400.00), measured against the member's same single deductible balance.
But wait - "the member's same single deductible balance" - this means the member's deductible balance is a single number that combines both in-network and out-of-network credits.
Let me think about this more carefully. Each member has a single deductible balance. When an in-network claim comes in, the deductible_applied is the lesser of the allowed amount and the family remainder (since it's aggregate). When an out-of-network claim comes in, the deductible_applied is the lesser of the allowed amount and the OON individual remainder (6400.00 minus the member's current deductible balance).
Wait, but the family deductible is also being tracked. Let me re-read.
"A member's own accumulator and the family accumulator both move on every claim that generates cost share."
So each member has:
- A deductible balance (single, combining IN and OON)
- An OOPM balance
And the family has:
- A family deductible balance
- A family OOPM balance
For in-network claims:
- deductible_applied = lesser of allowed amount and family remainder (6400.00 - family deductible balance)
- The member's deductible balance and family deductible balance both increase by deductible_applied
For out-of-network claims:
- deductible_applied = lesser of allowed amount and OON individual remainder (6400.00 - member's deductible balance)
- The member's deductible balance and family deductible balance both increase by deductible_applied
Once deductible is met:
- For in-network: when family deductible (6400.00) is met, all members get coinsurance
- For out-of-network: when member's OON deductible (6400.00) is met, that member gets coinsurance on OON claims
Wait, but the aggregate structure says "the plan pays no coinsurance for any member until total family credits reach the family deductible amount." Does this apply to OON claims too?
Let me re-read: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim."
So for OON claims, the deductible is measured against the OON individual threshold (6400.00) for that member, not the family deductible. But the credits still accumulate to the family balance.
Hmm, but then what happens when the family deductible is met for in-network claims? And what about the OON deductible?
Let me think about this differently. There seem to be two separate deductible thresholds:
1. Family deductible (6400.00) - aggregate, applies to in-network claims
2. OON individual deductible (6400.00) - applies to out-of-network claims for each member
But they share the same "single member deductible balance" - so credits from both IN and OON accumulate to the same balance.
Wait, I think I need to reconsider. Let me re-read the plan document:
"Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
"Out-of-network (individual) ............ 6400.00
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."
And from accumulators:
"in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);
out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."
OK so I think the structure is:
- There's a member deductible balance (single, shared between IN and OON)
- There's a family deductible balance
- For in-network claims: deductible_applied = min(allowed, family_remainder) where family_remainder = 6400.00 - family_deductible_balance. This is the aggregate rule.
- For out-of-network claims: deductible_applied = min(allowed, OON_individual_remainder) where OON_individual_remainder = 6400.00 - member_deductible_balance.
And both IN and OON deductible credits accumulate to both the member's deductible balance and the family deductible balance.
Now, when is coinsurance applied?
- For in-network: when the family deductible (6400.00) is met
- For out-of-network: when the member's OON deductible (6400.00) is met
But what if the family deductible is met but the member's OON deductible isn't? Or vice versa?
Actually, I think the way this works is:
- The family deductible (6400.00) is the aggregate threshold for in-network claims
- The OON individual deductible (6400.00) is the threshold for out-of-network claims for each member
- Both use the same underlying deductible credits (member balance and family balance)
So when an in-network claim comes in:
- If family_deductible_balance < 6400.00: deductible_applied = min(allowed, 6400.00 - family_deductible_balance), member pays deductible_applied, plan pays 0 (or rather, the remainder after deductible)
- If family_deductible_balance >= 6400.00: deductible_applied = 0, coinsurance applies (10% member / 90% plan)
When an out-of-network claim comes in:
- If member_deductible_balance < 6400.00: deductible_applied = min(allowed, 6400.00 - member_deductible_balance), member pays deductible_applied
- If member_deductible_balance >= 6400.00: deductible_applied = 0, coinsurance applies (40% member / 60% plan)
But wait, there's a subtlety. The family deductible and OON individual deductible are both 6400.00. Since all credits accumulate to both the member and family balances, and the family balance is the sum of all members' balances...
Actually, the family deductible balance is the sum of all members' deductible balances. So if the family balance reaches 6400.00, then at least one member must have reached 6400.00 individually? No, that's not right either - the family balance could be 6400.00 spread across multiple members.
Hmm, let me re-read: "A member's own accumulator and the family accumulator both move on every claim that generates cost share."
So the family accumulator is the sum of all members' accumulators? Or is it tracked separately?
I think the family deductible balance is the sum of all deductible_applied amounts across all members. And each member's deductible balance is the sum of their own deductible_applied amounts.
For the aggregate structure:
- In-network: deductible_applied is limited by the family remainder (6400.00 - family_balance)
- The member's balance and family balance both increase by deductible_applied
For OON:
- deductible_applied is limited by the OON individual remainder (6400.00 - member_balance)
- The member's balance and family balance both increase by deductible_applied
Now, for coinsurance:
- In-network: once family_balance >= 6400.00, coinsurance applies (10%/90%)
- OON: once member_balance >= 6400.00, coinsurance applies (40%/60%)
But what if family_balance >= 6400.00 but member_balance < 6400.00 for a specific member? Then for an in-network claim, coinsurance applies (family deductible met). For an OON claim for that member, the OON deductible might not be met yet.
Actually wait - if family_balance >= 6400.00, that means the total of all members' deductible balances is >= 6400.00. But an individual member's balance could be less than 6400.00.
Let me also think about the OOPM:
- In-network individual OOPM: 7000.00
- In-network family OOPM: 14000.00
- OON individual OOPM: 14000.00
"The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
So for OOPM, member_responsibility accumulates to both the member's OOPM balance and the family OOPM balance.
When does the OOPM kick in?
- In-network: once member's OOPM >= 7000.00 (individual) or family OOPM >= 14000.00 (family)?
- OON: once member's OOPM >= 14000.00
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."
And: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services."
Hmm, but for OON, the OOPM is 14000.00 individual. Let me think about what "reaches the OOPM" means.
I think:
- For in-network claims, once a member's OOPM balance >= 7000.00, the plan pays 100% for in-network services
- For out-of-network claims, once a member's OOPM balance >= 14000.00, the plan pays 100% for OON services
- But what about the family OOPM? "Family (in-network) .................... 14000.00"
With aggregate structure, I think the family OOPM works similarly to the family deductible - once the family OOPM (14000.00) is reached, all members get 100% for in-network services.
Actually, let me re-read the OOPM section:
"Individual (in-network) ................ 7000.00
Family (in-network) .................... 14000.00
Individual (out-of-network) ............ 14000.00"
I think for in-network:
- Each member has an individual OOPM of 7000.00
- The family OOPM is 14000.00
- Under aggregate structure, the family OOPM might work as the aggregate - once family OOPM reaches 14000.00, all members get 100%
But the plan says "Once a member reaches the out-of-pocket maximum" - this suggests individual OOPM.
Hmm, let me think about this differently. Let me just process the claims and track the accumulators.
Actually, I think the OOPM works like this:
- Each member tracks their own OOPM balance (sum of their member_responsibility)
- The family OOPM balance is the sum of all members' OOPM balances
- For in-network: if the member's OOPM >= 7000.00 OR the family OOPM >= 14000.00, the plan pays 100%
- For OON: if the member's OOPM >= 14000.00, the plan pays 100%
Actually, I'm not sure about the aggregate OOPM. Let me re-read the plan document.
"Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
This only talks about the deductible, not the OOPM. And the OOPM section says "Once a member reaches the out-of-pocket maximum the plan pays 100%."
So I think:
- Deductible: aggregate (family 6400.00 must be met for in-network coinsurance)
- OOPM: individual (7000.00 for in-network, 14000.00 for OON)
But there's also a family OOPM of 14000.00. I think the family OOPM might be a separate ceiling - once the family OOPM reaches 14000.00, all members get 100% for in-network services.
Let me just go with:
- In-network OOPM: member pays coinsurance until their individual OOPM reaches 7000.00, then plan pays 100%
- Family OOPM: once family total OOPM reaches 14000.00, all members get 100% for in-network
- OON OOPM: member pays coinsurance until their individual OOPM reaches 14000.00, then plan pays 100%
Now let me also consider: what happens when the OOPM is reached? The member_responsibility for that claim would be just enough to reach the OOPM, and the plan pays the rest.
Let me also note: "Premiums and non-covered services never count toward it." So only covered services' member cost share counts toward OOPM.
Now, let me also consider preventive services:
- "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."
- "An out-of-network preventive service is subject to the out-of-network deductible and coinsurance."
So which claims are preventive?
- Line 20: Routine immunisation, in-network - this is preventive (in-network), so 100% covered, no cost share
- Line 11: Annual wellness visit, out-of-network - this is preventive but OON, so subject to OON deductible and coinsurance
- Line 13: Screening colonoscopy, no polyp removed, out-of-network - this is preventive but OON, so subject to OON deductible and coinsurance
Wait, let me check which services are preventive:
- Routine immunisation - preventive
- Annual wellness visit - preventive
- Screening colonoscopy - preventive (screening)
Other services:
- Generic retail pharmacy fill - not preventive
- Inpatient admission - not preventive
- Diagnostic laboratory panel - not preventive (unless it's a screening lab, but it doesn't say screening)
- Urgent care visit - not preventive
- Emergency department visit - not preventive
- Allergy testing - not preventive
- Ambulatory surgery - not preventive
- Outpatient endoscopy - not preventive (unless specified as screening)
- Physical therapy - not preventive
- Primary care office visit - not preventive (unless it's a wellness visit)
OK so:
- Line 20 (Routine immunisation, in-network): preventive, in-network → 100% covered, no cost share, no accumulator movement
- Line 11 (Annual wellness visit, OON): preventive but OON → subject to OON deductible and coinsurance
- Line 13 (Screening colonoscopy, OON): preventive but OON → subject to OON deductible and coinsurance
Now let me process all 25 lines in order, tracking the accumulators.
Let me set up the tracking:
Member balances:
A: deductible = 0.00, OOPM = 0.00
B: deductible = 0.00, OOPM = 0.00
C: deductible = 0.00, OOPM = 0.00
D: deductible = 0.00, OOPM = 0.00
E: deductible = 0.00, OOPM = 0.00
Family: deductible = 0.00, OOPM = 0.00
Constants:
- Family deductible (in-network, aggregate): 6400.00
- OON individual deductible: 6400.00
- In-network individual OOPM: 7000.00
- In-network family OOPM: 14000.00
- OON individual OOPM: 14000.00
- In-network coinsurance: 10% member / 90% plan
- OON coinsurance: 40% member / 60% plan
Let me process each line:
**Line 1 — Claim 1 — 2026-01-07 — A (subscriber)**
Service: Generic retail pharmacy fill, in-network
Allowed: 74.87
Not preventive. In-network.
Family deductible remainder: 6400.00 - 0.00 = 6400.00
deductible_applied = min(74.87, 6400.00) = 74.87
member_responsibility = 74.87 (all goes to deductible)
plan_paid = 0.00
coinsurance_amount = 0.00
copay_amount = 0.00
A: deductible = 74.87, OOPM = 74.87
Family: deductible = 74.87, OOPM = 74.87
**Line 2 — Claim 2 — 2026-01-17 — C (child)**
Service: Inpatient admission, OON
Allowed: 10883.95
Not preventive. OON.
OON individual deductible: 6400.00
C's deductible balance: 0.00
OON individual remainder: 6400.00 - 0.00 = 6400.00
deductible_applied = min(10883.95, 6400.00) = 6400.00
Remaining after deductible: 10883.95 - 6400.00 = 4483.95
coinsurance_amount = 4483.95 * 40% = 1793.58
member_responsibility = 6400.00 + 1793.58 = 8193.58
plan_paid = 4483.95 * 60% = 2690.37
Wait, let me check OOPM. C's OOPM before this claim: 0.00
OOPM threshold for OON: 14000.00
C's OOPM after this claim: 8193.58, which is < 14000.00, so no OOPM cap.
Actually wait - I need to think about whether the OOPM limits the member_responsibility. The member_responsibility is 8193.58, and the OOPM is 14000.00, so it's not reached. OK.
C: deductible = 6400.00, OOPM = 8193.58
Family: deductible = 74.87 + 6400.00 = 6474.87, OOPM = 74.87 + 8193.58 = 8268.45
**Line 3 — Claim 3 — 2026-02-01 — C (child)**
Service: Diagnostic laboratory panel, OON
Allowed: 967.99
Not preventive. OON.
C's deductible balance: 6400.00
OON individual remainder: 6400.00 - 6400.00 = 0.00
deductible_applied = min(967.99, 0.00) = 0.00
Remaining after deductible: 967.99
coinsurance_amount = 967.99 * 40% = 387.196 → 387.20
member_responsibility = 0.00 + 387.20 = 387.20
plan_paid = 967.99 * 60% = 580.794 → 580.79
Wait, let me recalculate: 967.99 * 0.40 = 387.196, rounds to 387.20
967.99 * 0.60 = 580.794, rounds to 580.79
387.20 + 580.79 = 967.99 ✓
C: deductible = 6400.00, OOPM = 8193.58 + 387.20 = 8580.78
Family: deductible = 6474.87, OOPM = 8268.45 + 387.20 = 8655.65
**Line 4 — Claim 4 — 2026-02-15 — A (subscriber)**
Service: Urgent care visit, in-network
Allowed: 255.34
Not preventive. In-network.
Family deductible: 6474.87
Family remainder: 6400.00 - 6474.87 = -74.87 → already met!
Wait, family deductible is already met (6474.87 > 6400.00). So for in-network, the family deductible is met.
deductible_applied = 0.00 (family deductible already met)
coinsurance_amount = 255.34 * 10% = 25.534 → 25.53
member_responsibility = 25.53
plan_paid = 255.34 * 90% = 229.806 → 229.81
Wait, 25.53 + 229.81 = 255.34 ✓
A: deductible = 74.87 (no change, deductible_applied = 0), OOPM = 74.87 + 25.53 = 100.40
Family: deductible = 6474.87 (no change), OOPM = 8655.65 + 25.53 = 8681.18
**Line 5 — Claim 5 — 2026-03-01 — A (subscriber)**
Service: Emergency department visit, in-network
Allowed: 3545.18
Not preventive. In-network.
Family deductible already met (6474.87 > 6400.00).
deductible_applied = 0.00
coinsurance_amount = 3545.18 * 10% = 354.518 → 354.52
member_responsibility = 354.52
plan_paid = 3545.18 * 90% = 3190.662 → 3190.66
354.52 + 3190.66 = 3545.18 ✓
A: deductible = 74.87, OOPM = 100.40 + 354.52 = 454.92
Family: deductible = 6474.87, OOPM = 8681.18 + 354.52 = 9035.70
**Line 6 — Claim 6 — 2026-03-07 — A (subscriber)**
Service: Allergy testing, in-network
Allowed: 911.89
Not preventive. In-network.
Family deductible already met.
deductible_applied = 0.00
coinsurance_amount = 911.89 * 10% = 91.189 → 91.19
member_responsibility = 91.19
plan_paid = 911.89 * 90% = 820.701 → 820.70
91.19 + 820.70 = 911.89 ✓
A: deductible = 74.87, OOPM = 454.92 + 91.19 = 546.11
Family: deductible json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 25,493 tokens
Let me work through this ledger step by step, processing each claim in order and tracking the accumulators.
**Plan rules:**
- Aggregate deductible: Family must meet 6400.00 (in-network) before any coinsurance. No individual deductible under aggregate structure.
- Out-of-network individual deductible: 6400.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance.
- Coinsurance: 10% member / 90% plan (in-network), 40% member / 60% plan (out-of-network)
- OOPM: Individual in-network 7000.00, Family in-network 14000.00, Individual out-of-network 14000.00
- No copays
- Preventive services in-network: no cost share, no accumulator movement
- Out-of-network preventive: subject to out-of-network deductible and coinsurance
Wait, let me re-read the deductible rules more carefully.
"Structure ... AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
So for in-network claims, the family deductible of 6400.00 must be met before any coinsurance.
"Out-of-network (individual) ... 6400.00"
"In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
So there's a single deductible balance per member. For in-network, it's measured against... the aggregate family deductible (6400.00). For out-of-network, it's measured against the out-of-network individual threshold (6400.00).
Wait, but the aggregate structure says "the plan pays no coinsurance for any member until total family credits reach the family deductible amount." So for in-network claims, we need the family deductible of 6400.00 to be met.
For out-of-network claims: "the out-of-network individual remainder, measured against the member's same single deductible balance."
Let me re-read the accumulators section:
"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);
out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."
So for in-network (aggregate): deductible_applied = min(allowed amount, family remainder)
For out-of-network: deductible_applied = min(allowed amount, out-of-network individual remainder)
The out-of-network individual threshold is 6400.00, measured against the member's single deductible balance.
The in-network family deductible is 6400.00.
So both in-network and out-of-network use the same threshold amount (6400.00 for the family in-network, 6400.00 for out-of-network individual).
Wait, but the in-network individual deductible is 3200.00, and family is 6400.00. Under aggregate, there's no individual deductible. So in-network claims use the family remainder (6400.00 - family deductible balance).
Out-of-network claims use the out-of-network individual remainder (6400.00 - member's single deductible balance).
But the key is: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
So each member has one deductible balance. And the family has one deductible balance (sum of all members? Or just the family total?).
Let me think about this more carefully.
Under aggregate structure:
- There's a family deductible of 6400.00
- The plan pays no coinsurance for any member until total family credits reach 6400.00
- "There is no individual deductible under this structure"
So the family deductible balance is the sum of all deductible_applied amounts across all members.
For in-network claims, deductible_applied = min(allowed amount, family remainder) where family remainder = 6400.00 - family deductible balance.
For out-of-network claims, deductible_applied = min(allowed amount, out-of-network individual remainder) where out-of-network individual remainder = 6400.00 - member's single deductible balance.
But both types of deductible_applied credits go to the member's balance AND the family balance.
Let me track:
- Member deductible balance for each member (A, B, C, D, E)
- Family deductible balance (sum of all member balances? Or tracked separately?)
Actually, under aggregate, the family deductible is 6400.00. The family balance is the total of all deductible credits across all family members.
Let me also track:
- Member out-of-pocket balance for each member (sum of member_responsibility)
- Family out-of-pocket balance (sum of all member OOP balances)
Now let me process each claim.
**Starting state:**
- All member deductible balances: 0.00
- All member OOP balances: 0.00
- Family deductible balance: 0.00
- Family OOP balance: 0.00
**Line 1 — Claim 1 — A (subscriber) — In-network pharmacy**
- Allowed: 74.87
- In-network, aggregate: deductible_applied = min(74.87, 6400.00 - 0.00) = 74.87
- Deductible met? No (family balance would be 74.87, threshold 6400.00)
- Since deductible not met, member pays the full deductible_applied amount
- member_responsibility = 74.87 (the deductible portion)
- Wait, but is this a preventive service? "Generic retail pharmacy fill" - not preventive.
- deductible_applied = 74.87
- member_responsibility = 74.87 (all goes to deductible since deductible not met)
- plan_paid = 0.00
- copay = 0.00
- coinsurance = 0.00
After Line 1:
- A deductible: 74.87
- A OOP: 74.87
- Family deductible: 74.87
- Family OOP: 74.87
**Line 2 — Claim 2 — C (child) — Out-of-network inpatient**
- Allowed: 10883.95
- Out-of-network: deductible_applied = min(10883.95, 6400.00 - C's deductible balance)
- C's deductible balance = 0.00
- Out-of-network individual remainder = 6400.00 - 0.00 = 6400.00
- deductible_applied = min(10883.95, 6400.00) = 6400.00
- After deductible: remaining = 10883.95 - 6400.00 = 4483.95
- Out-of-network coinsurance: 40% member / 60% plan
- member coinsurance = 4483.95 * 0.40 = 1793.58
- plan coinsurance = 4483.95 * 0.60 = 2690.37
- member_responsibility = 6400.00 + 1793.58 = 8193.58
- plan_paid = 2690.37
- copay = 0.00
- coinsurance = 1793.58
Wait, but I need to check the OOPM. Out-of-network individual OOPM is 14000.00.
- C's OOP before = 0.00
- C's OOP after = 8193.58 (under 14000.00, so no cap)
- Family OOP before = 74.87
- Family OOP after = 74.87 + 8193.58 = 8268.45
Wait, but the family OOPM is 14000.00 (in-network). Does the family OOPM apply to out-of-network claims?
"Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim."
So for OOPM, out-of-network claims are measured against the out-of-network individual OOPM (14000.00), not the family OOPM.
But the credits still accumulate to the family OOP balance.
Hmm, but what does the family OOPM mean then? Let me think...
The family OOPM is 14000.00 (in-network). Once a member reaches the individual OOPM (7000.00 in-network or 14000.00 out-of-network), the plan pays 100% for that member.
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."
So OOPM is per-member. The family OOPM might mean that once the family total reaches 14000.00, all members get 100%? Let me re-read...
"Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year."
Individual OOPM: 7000.00 (in-network), 14000.00 (out-of-network)
Family OOPM: 14000.00 (in-network)
Under aggregate deductible, there's no individual deductible, but there could still be individual OOPM or family OOPM.
Actually, the question is whether the OOPM is embedded or aggregate. The plan says "Aggregate" for the deductible structure. It doesn't explicitly say for OOPM.
Let me re-read the plan document:
"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 it's per-member. But there's also a family OOPM of 14000.00. Under a family OOPM, once the family total reaches 14000.00, all members get 100%.
Let me think about this differently. The OOPM accumulators track:
- Member OOP balance: sum of member_responsibility for that member
- Family OOP balance: sum of all member OOP balances
The individual OOPM limits each member's cost share. The family OOPM limits the total family cost share.
But which OOPM applies? In-network or out-of-network?
For in-network services, the in-network individual OOPM (7000.00) and family OOPM (14000.00) apply.
For out-of-network services, the out-of-network individual OOPM (14000.00) applies.
But the credits accumulate to the same balance? Or different balances?
Let me re-read: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
This is about deductible. For OOPM, it says:
"Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year."
Let me look at the accumulators section again:
"A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
So there's a single OOP balance per member (just like a single deductible balance). And a single family OOP balance.
The in-network individual OOPM is 7000.00, and the out-of-network individual OOPM is 14000.00. But the balance is the same for both.
So if a member's OOP balance reaches 7000.00 (through in-network claims), does the plan start paying 100% for in-network claims but not out-of-network? Or does it pay 100% for all claims?
Hmm, this is getting complex. Let me re-read more carefully.
"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 has in-network and out-of-network amounts. I think:
- In-network OOPM: 7000.00 individual, 14000.00 family
- Out-of-network OOPM: 14000.00 individual
So for an in-network claim, if the member's OOP balance >= 7000.00 (individual) or family OOP balance >= 14000.00 (family), the plan pays 100%.
For an out-of-network claim, if the member's OOP balance >= 14000.00, the plan pays 100%.
But the balance is shared. So if a member has 8000.00 in OOP from in-network claims, and then has an out-of-network claim, the out-of-network OOPM is 14000.00, so the member still has 6000.00 of room.
But wait, if the member has 8000.00 from in-network claims, the in-network OOPM of 7000.00 is already met, so in-network claims would be paid at 100%. But out-of-network claims would still need to reach 14000.00.
Actually, I think the OOPM works like this: the OOP balance is the same, but the threshold depends on the network:
- In-network: 7000.00 individual, 14000.00 family
- Out-of-network: 14000.00 individual
And once the applicable threshold is met, the plan pays 100%.
But the accumulator section says: "the balances are not capped at the in-network amounts." So the balance can go above 7000.00 or 14000.00.
OK, I think I need to just track:
- Member OOP balance (single, shared)
- Family OOP balance (single, shared)
And for each claim:
- If in-network and member OOP >= 7000.00 OR family OOP >= 14000.00: plan pays 100%
- If out-of-network and member OOP >= 14000.00: plan pays 100%
Wait, but that doesn't quite work either. Let me think again...
Actually, I think the in-network and out-of-network OOPM are separate thresholds on the same balance. The in-network individual OOPM is 7000.00 - once the member's OOP balance reaches 7000.00, in-network claims are paid at 100%. The out-of-network individual OOPM is 14000.00 - once the member's OOP balance reaches 14000.00, out-of-network claims are also paid at 100%.
But I'm not sure about the family OOPM. Let me re-read:
"Individual (in-network) ................ 7000.00
Family (in-network) .................... 14000.00
Individual (out-of-network) ............ 14000.00"
There's no family out-of-network OOPM. And the plan says "Once a member reaches the out-of-pocket maximum the plan pays 100%..."
So the OOPM is per-member (individual) or per-family. The family OOPM of 14000.00 means once the family's total OOP reaches 14000.00, all members get 100% for in-network claims.
But for out-of-network, only the individual OOPM of 14000.00 applies (there's no family out-of-network OOPM).
Let me also consider: does the family OOPM apply to all claims or just in-network? It's labeled "Family (in-network)" so it applies to in-network claims. But if the family OOP balance reaches 14000.00, do all members get 100% for in-network? I think yes.
And "the family amounts, which are in-network amounts, do not limit an out-of-network claim." So the family OOPM doesn't limit out-of-network claims.
OK, so let me also think about the family deductible. Under aggregate:
- Family in-network deductible: 6400.00
- The family deductible balance is the sum of all deductible_applied amounts.
- For in-network claims, deductible_applied = min(allowed, family remainder) where family remainder = 6400.00 - family deductible balance.
- For out-of-network claims, deductible_applied = min(allowed, out-of-network individual remainder) where out-of-network individual remainder = 6400.00 - member's deductible balance.
But both in-network and out-of-network deductible credits go to the member's balance AND the family balance.
And for in-network claims, once the family deductible is met (family balance >= 6400.00), the plan starts paying coinsurance.
Wait, but under aggregate, the deductible threshold for in-network is the family amount (6400.00). So:
- For in-network claims, deductible_applied = min(allowed, 6400.00 - family deductible balance)
- Once family deductible balance reaches 6400.00, in-network claims go to coinsurance.
For out-of-network claims:
- deductible_applied = min(allowed, 6400.00 - member's deductible balance)
- Once member's deductible balance reaches 6400.00, out-of-network claims go to coinsurance for that member.
But the member's deductible balance includes both in-network and out-of-network credits. And the family deductible balance also includes both.
So if the family deductible balance reaches 6400.00 (through any combination of in-network and out-of-network claims), in-network claims start getting coinsurance.
And if a member's deductible balance reaches 6400.00 (through any combination), out-of-network claims for that member start getting coinsurance.
Actually, wait. The in-network deductible threshold is the family amount (6400.00), but under aggregate, the deductible_applied for in-network is "the family remainder alone." So the in-network deductible is based on the family balance, not the member balance.
But for out-of-network, the deductible is based on the member's individual balance (against the 6400.00 out-of-network threshold).
And both contribute to both the member balance and the family balance.
OK let me just carefully process each claim.
Let me define:
- For each member: ded_bal[m] = sum of deductible_applied for that member
- Family: ded_bal_fam = sum of all ded_bal[m]
- For each member: oop_bal[m] = sum of member_responsibility for that member
- Family: oop_bal_fam = sum of all oop_bal[m]
**Line 1 — Claim 1 — A — In-network pharmacy**
- Allowed: 74.87
- In-network, aggregate
- Family remainder = 6400.00 - 0.00 = 6400.00
- deductible_applied = min(74.87, 6400.00) = 74.87
- Family deductible met? No (0.00 + 74.87 = 74.87 < 6400.00)
- member_responsibility = 74.87 (all deductible, no coinsurance since deductible not met)
- plan_paid = 0.00
- copay = 0.00
- coinsurance = 0.00
After:
- A ded: 74.87, A oop: 74.87
- Family ded: 74.87, Family oop: 74.87
**Line 2 — Claim 2 — C — Out-of-network inpatient**
- Allowed: 10883.95
- Out-of-network
- C's deductible balance = 0.00
- Out-of-network individual remainder = 6400.00 - 0.00 = 6400.00
- deductible_applied = min(10883.95, 6400.00) = 6400.00
- Remaining after deductible: 10883.95 - 6400.00 = 4483.95
- Out-of-network coinsurance: 40% member
- But wait, need to check OOPM. C's OOP = 0.00, out-of-network individual OOPM = 14000.00. Not met.
- coinsurance_amount = 4483.95 * 0.40 = 1793.58
- member_responsibility = 6400.00 + 1793.58 = 8193.58
- plan_paid = 4483.95 * 0.60 = 2690.37
- copay = 0.00
Let me verify: 6400.00 + 1793.58 + 2690.37 = 10883.95. ✓
And 1793.58 + 2690.37 = 4483.95. ✓
After:
- C ded: 6400.00, C oop: 8193.58
- Family ded: 74.87 + 6400.00 = 6474.87
- Family oop: 74.87 + 8193.58 = 8268.45
**Line 3 — Claim 3 — C — Out-of-network lab panel**
- Allowed: 967.99
- Out-of-network
- C's deductible balance = 6400.00
- Out-of-network individual remainder = 6400.00 - 6400.00 = 0.00
- deductible_applied = min(967.99, 0.00) = 0.00
- Remaining after deductible: 967.99 - 0.00 = 967.99
- Out-of-network coinsurance: 40% member
- C's OOP = 8193.58, out-of-network individual OOPM = 14000.00. Not met.
- coinsurance_amount = 967.99 * 0.40 = 387.20 (rounding: 967.99 * 0.40 = 387.196, round to 387.20)
- member_responsibility = 0.00 + 387.20 = 387.20
- plan_paid = 967.99 * 0.60 = 580.79 (967.99 * 0.60 = 580.794, round to 580.79)
- copay = 0.00
Let me verify: 387.20 + 580.79 = 967.99. ✓
After:
- C ded: 6400.00, C oop: 8193.58 + 387.20 = 8580.78
- Family ded: 6474.87, Family oop: 8268.45 + 387.20 = 8655.65
**Line 4 — Claim 4 — A — In-network urgent care**
- Allowed: 255.34
- In-network, aggregate
- Family remainder = 6400.00 - 6474.87 = -74.87 → 0 (family deductible met)
- Wait, family deductible balance is 6474.87, which is > 6400.00, so the family deductible is met.
- deductible_applied = min(255.34, 0.00) = 0.00 (family remainder is 0 because deductible met)
- Family deductible met, so coinsurance applies.
- In-network coinsurance: 10% member
- A's OOP = 74.87, in-network individual OOPM = 7000.00. Not met.
- Family OOP = 8655.65, family in-network OOPM = 14000.00. Not met.
- coinsurance_amount = 255.34 * 0.10 = 25.53
- member_responsibility = 0.00 + 25.53 = 25.53
- plan_paid = 255.34 * 0.90 = 229.81 (255.34 * 0.90 = 229.806, round to 229.81)
- copay = 0.00
Verify: 25.53 + 229.81 = 255.34. ✓
After:
- A ded: 74.87, A oop: 74.87 + 25.53 = 100.40
- Family ded: 6474.87, Family oop: 8655.65 + 25.53 = 8681.18
**Line 5 — Claim 5 — A — In-network ED visit**
- Allowed: 3545.18
- In-network, aggregate
- Family deductible met (6474.87 >= 6400.00)
- deductible_applied = 0.00
- In-network coinsurance: 10% member
- A's OOP = 100.40, OOPM not met.
- Family OOP = 8681.18, not met.
- coinsurance_amount = 3545.18 * 0.10 = 354.52 (3545.18 * 0.10 = 354.518, round to 354.52)
- member_responsibility = 354.52
- plan_paid = 3545.18 * 0.90 = 3190.66 (3545.18 * 0.90 = 3190.662, round to 3190.66)
- copay = 0.00
Verify: 354.52 + 3190.66 = 3545.18. ✓
After:
- A ded: 74.87, A oop: 100.40 + 354.52 = 454.92
- Family ded: 6474.87, Family oop: 8681.18 + 354.52 = 9035.70
**Line 6 — Claim 6 — A — In-network allergy testing**
- Allowed: 911.89
- In-network, aggregate
- Family deductible met
- deductible_applied = 0.00
- In-network coinsurance: 10% member
- coinsurance_amount = 911.89 * 0.10 = 91.19 (911.89 * 0.10 = 91.189, round to 91.19)
- member_responsibility = 91.19
- plan_paid = 911.89 * 0.90 = 820.70 (911.89 * 0.90 = 820.701, round to 820.70)
- copay = 0.00
Verify: 91.19 + 820.70 = 911.89. ✓
After:
- A ded: 74.87, A oop: 454.92 + 91.19 = 546.11
- Family ded: 6474.87, Family oop: 9035.70 + 91.19 = 9126.89
**Line 7 — Claim 7 — B — In-network ambulatory surgery**
- Allowed: 7845.50
- In-network, aggregate
- Family deductible met
- deductible_applied = 0.00
- In-networkjson{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 13,798 tokens
Let me carefully work through this ledger step by step.
Plan details:
- Individual in-network deductible: 3200.00
- Family in-network deductible: 6400.00 (AGGREGATE - family amount must be met before any coinsurance)
- Out-of-network individual deductible: 6400.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance
- Out-of-network threshold is 6400.00 for individual
- OOPM: Individual in-network 7000, Family in-network 14000, Individual out-of-network 14000
- Coinsurance: in-network 10% member / 90% plan; out-of-network 40% member / 60% plan
- No copays
- Preventive services in-network: 100% covered, no cost share, no accumulator movement
- Out-of-network preventive services: subject to OON deductible and coinsurance
Aggregate deductible: family amount (6400.00) must be satisfied in full before plan pays coinsurance for any member. But wait - the aggregate structure applies to in-network. What about out-of-network?
Let me re-read the plan document carefully.
"Structure: AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
"Out-of-network (individual): 6400.00"
"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 in-network claims, the aggregate family deductible of 6400 must be met before coinsurance. For out-of-network claims, they're measured against the out-of-network individual deductible of 6400.
Wait, let me re-read the accumulators section:
"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);
out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."
So:
- In-network: deductible_applied is the lesser of allowed amount and family remainder (aggregate). Family deductible threshold is 6400.
- Out-of-network: deductible_applied is the lesser of allowed amount and OON individual remainder (6400 - member's deductible balance).
Wait, but the member's deductible balance and family balance - are they the same thing or different?
Let me re-read: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
So each member has a single deductible balance. The family total is the sum of all members' balances.
For in-network claims under aggregate: deductible_applied = lesser of allowed amount and family remainder (6400 - family total).
For out-of-network claims: deductible_applied = lesser of allowed amount and OON individual remainder (6400 - member's balance).
Wait, but the OON threshold is 6400 and the family in-network threshold is also 6400. And credits accumulate to a single balance. So in practice, once the family total reaches 6400, all in-network claims are past deductible, and each member's OON individual threshold of 6400 would also be met if their personal balance reaches 6400.
Hmm, but let me think about this more carefully. The family deductible is 6400 aggregate. Each member has a single deductible balance. The family total is the sum of all members' balances.
For an in-network claim:
- deductible_applied = lesser of allowed amount and (6400 - family_total)
- Once family_total reaches 6400, deductible_applied = 0, coinsurance begins
For an out-of-network claim:
- deductible_applied = lesser of allowed amount and (6400 - member's individual balance)
- Once member's balance reaches 6400, deductible_applied = 0, coinsurance begins
But wait - for in-network under aggregate, it says "the family remainder alone (aggregate)". So it's 6400 - family_total. And for OON, it's 6400 - member's individual balance.
But here's the thing: under aggregate, a member's in-network claim is measured against the family remainder, not their individual balance. So a member could have 0 personal balance but if family total is 6400, their in-network claim would have deductible_applied = 0.
Actually, let me re-read: "Under an aggregate structure no member reaches coinsurance until the family amount is met." So for in-network, the family deductible (6400) must be met. The deductible_applied for in-network is the lesser of allowed amount and (6400 - family_total).
For out-of-network, the OON individual deductible (6400) must be met for that member. deductible_applied = lesser of allowed amount and (6400 - member_balance).
Now, when an in-network claim generates deductible_applied, it adds to both the member's balance and the family total. When an OON claim generates deductible_applied, it also adds to both.
But the threshold for in-network is family 6400, and for OON it's individual 6400. Since family total >= any individual balance, the family threshold could be met before an individual's OON threshold. But in-network claims use family remainder, OON claims use individual remainder.
Let me also think about OOPM.
"Out-of-pocket maximum (OOPM): Individual (in-network) 7000.00, Family (in-network) 14000.00, Individual (out-of-network) 14000.00"
"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 OOPM is tracked per member. The individual in-network OOPM is 7000, and the individual OON OOPM is 14000. But do these combine? 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 for OOPM.
Looking at the OOPM section: Individual in-network 7000, Family in-network 14000, Individual OON 14000. It seems like OOPM might have separate in-network and OON tracking, but the problem says "A balance is the running total of member_responsibility (for an out-of-pocket balance)."
Hmm, let me think about this differently. The accumulators section says: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)."
So the OOPM balance is the running total of member_responsibility for each member. And the family OOPM is the sum of all members' OOPM balances.
The question is: what threshold applies? For in-network services, the individual OOPM is 7000 and family OOPM is 14000. For OON services, the individual OOPM is 14000.
But since the plan says "Once a member reaches the out-of-pocket maximum the plan pays 100%", I think the OOPM is a single balance per member, and the threshold depends on the service type. Actually, let me re-read more carefully.
"Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services."
From the general rules: "Premiums and non-covered services never count toward it."
Looking at the plan document, it lists:
- Individual (in-network) 7000
- Family (in-network) 14000
- Individual (out-of-network) 14000
And: "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."
I think the OOPM works like this: each member has a single OOPM balance (running total of member_responsibility). For in-network services, the threshold is 7000 individual / 14000 family. For OON services, the threshold is 14000 individual. Once a member's OOPM balance reaches the applicable threshold, the plan pays 100%.
Actually, I think it might be simpler. Let me re-read the accumulator rules:
"A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
So the OOPM balance is simply the running total of member_responsibility. The thresholds are:
- In-network individual: 7000
- In-network family: 14000
- OON individual: 14000
For an in-network claim, if the member's OOPM balance >= 7000 (or family >= 14000?), the plan pays 100%. Wait, but for family OOPM, once the family total reaches 14000, does the plan pay 100% for all members?
Hmm, the general rules say: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered in-network services for the remainder of the plan year." This suggests it's per member, not family.
But the plan lists a family OOPM. Let me think about this...
Actually, in real HDHP plans, the family OOPM means that once the family's total OOP spending reaches the family OOPM, all members get 100% coverage. But in this problem, the general rules say "Once a member reaches the out-of-pocket maximum..." which suggests per-member.
Let me re-read: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services."
And: "Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000"
I think the family OOPM works like the family deductible - once the family total reaches 14000, all members get 100% coverage. But let me check if the accumulator rules mention family OOPM.
The accumulator rules say: "A balance is the running total of member_responsibility (for an out-of-pocket balance)." And mentions "family balances" in the context of deductibles.
Actually, let me look at the task family rules: "A member's own accumulator and the family accumulator both move on every claim that generates cost share."
So there are family accumulators for both deductible and OOPM. The family OOPM threshold is 14000 (in-network). Once the family OOPM reaches 14000, the plan pays 100% for all members? Or once an individual member's OOPM reaches 7000?
I think both apply: if either the member's individual OOPM reaches 7000 (in-network) or the family OOPM reaches 14000, the plan pays 100%.
But wait, the OON OOPM is 14000 individual. So for OON claims, the threshold is 14000 for the individual.
Let me think about how to apply this. For each claim:
1. Check if the member's OOPM balance has reached the applicable threshold. For in-network, threshold is 7000 (individual) or 14000 (family). For OON, threshold is 14000 (individual).
2. If threshold reached, plan pays 100%, member pays 0.
3. If not, calculate deductible_applied and coinsurance.
Actually, I need to think about whether the family OOPM threshold applies to in-network claims. The plan says "Family (in-network) 14000". So once family OOPM >= 14000, in-network claims are 100% covered. But what about OON claims when family OOPM >= 14000 but individual OOPM < 14000? The OON individual threshold is 14000, so the member would still need to reach 14000 individually.
Hmm, but the general rules say "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered in-network services." This implies the OOPM check is per-member, not per-family. But then why list a family OOPM?
Let me take a step back. In the real world, for HDHPs, the family OOPM means that once the family's total OOP spending reaches the family OOPM limit, all family members are protected. But the problem's general rules emphasize "Once a member reaches..." Let me look at the task rules again.
"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. Under an aggregate structure no member reaches coinsurance until the family amount is met."
This talks about deductible structure. For OOPM, the general rules say: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services."
I think the OOPM works similarly to the deductible: the family OOPM is a threshold, and once the family total reaches it, all members get 100% coverage for in-network services. For OON services, the individual OON OOPM of 14000 applies.
But actually, let me think about this differently. The problem mentions both individual and family OOPM. I think the logic is:
- For in-network services: if member's OOPM >= 7000 OR family OOPM >= 14000, plan pays 100%.
- For OON services: if member's OOPM >= 14000, plan pays 100%. (Family OOPM doesn't apply to OON since the family OOPM is an in-network amount.)
Wait, but the accumulator section says: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." This is about deductibles, but the same logic might apply to OOPM.
Let me just go with:
- In-network: member pays 0 if member OOPM >= 7000 or family OOPM >= 14000
- OON: member pays 0 if member OOPM >= 14000
Now let me process the ledger.
I'll track for each member: deductible balance, OOPM balance. And family: deductible total, OOPM total.
For deductible:
- In-network: deductible_applied = min(allowed, 6400 - family_deductible_total). If family_deductible_total >= 6400, deductible_applied = 0.
- OON: deductible_applied = min(allowed, 6400 - member_deductible_balance). If member_deductible_balance >= 6400, deductible_applied = 0.
After deductible is applied, if deductible_applied < allowed (meaning deductible was met for this claim or was already met), coinsurance applies on the remainder.
For in-network coinsurance: 10% member, 90% plan
For OON coinsurance: 40% member, 60% plan
Member responsibility = deductible_applied + coinsurance_amount
Plan paid = allowed - member_responsibility
But if OOPM is reached, member responsibility = 0, plan paid = allowed.
Let me also check: preventive services in-network are 100% covered with no cost share and don't move accumulators. Out-of-network preventive services are subject to OON deductible and coinsurance.
Let me identify which services are preventive:
- Line 1: Generic retail pharmacy fill - not preventive (it's pharmacy)
- Line 11: Annual wellness visit - preventive, but OON, so subject to OON deductible/coinsurance
- Line 13: Screening colonoscopy, no polyp removed - preventive, but OON, so subject to OON deductible/coinsurance
- Line 20: Routine immunisation, in-network - preventive, 100% covered, no accumulator movement
- Line 17: Physical therapy course - not preventive
Actually, let me reconsider. "Routine immunisation" is preventive. "Annual wellness visit" is preventive. "Screening colonoscopy" is preventive. All the other services are not preventive.
Line 20: Routine immunisation, in-network - preventive, so 100% covered, no cost share, no accumulator movement.
But then Line 23 is an ADJUSTMENT to Claim 20. The adjustment corrects the allowed amount downward. Since it was preventive and in-network, it was 100% covered with no cost share. The adjustment would change the allowed amount but since it's still 100% covered (preventive in-network), the member responsibility remains 0, plan paid = corrected allowed amount.
Wait, but the adjustment unwinds the credits and re-adjudicates. Since the original claim had no cost share (preventive in-network), there were no credits to unwind (no deductible_applied, no member_responsibility). The re-adjudication would be at the new allowed amount, still 100% covered, no cost share.
Hmm, but actually, even for preventive services with no cost share, does the plan payment change? The plan paid 1243.12 originally (100% of allowed). After adjustment, the plan pays 745.87 (100% of corrected allowed). But since there was no member responsibility and no deductible_applied, the only change is the plan paid amount. But the accumulator doesn't change because preventive in-network services don't move accumulators.
Wait, does the plan payment count as an "accumulator"? The accumulators we track are deductible and OOPM. Plan payments don't affect those. So the adjustment to Claim 20 only changes plan_paid but doesn't affect any accumulators.
Actually, let me re-read: "ADJUSTMENT. When a line is an adjustment to an earlier claim, the credits that claim generated — its deductible credit and its member responsibility — are removed from every accumulator they touched."
So for Claim 20 (preventive, in-network), the deductible credit was 0 and member responsibility was 0. So there's nothing to unwind. The re-adjudication at 745.87 still gives deductible_applied = 0, member_responsibility = 0, plan_paid = 745.87.
OK, now let me process each line carefully.
Initial state:
All members: deductible = 0, OOPM = 0
Family: deductible = 0, OOPM = 0
**Line 1 — Claim 1 — A — Generic retail pharmacy fill, in-network — Allowed: 74.87**
In-network. Not preventive.
Family deductible total = 0. Family remainder = 6400 - 0 = 6400.
deductible_applied = min(74.87, 6400) = 74.87
Remaining after deductible = 74.87 - 74.87 = 0
Coinsurance = 0 (no remainder)
Member responsibility = 74.87 + 0 = 74.87
Plan paid = 0
A deductible: 0 + 74.87 = 74.87
A OOPM: 0 + 74.87 = 74.87
Family deductible: 0 + 74.87 = 74.87
Family OOPM: 0 + 74.87 = 74.87
**Line 2 — Claim 2 — C — Inpatient admission, OON — Allowed: 10883.95**
OON. Not preventive.
C's deductible balance = 0. OON individual threshold = 6400.
OON individual remainder = 6400 - 0 = 6400.
deductible_applied = min(10883.95, 6400) = 6400
Remaining after deductible = 10883.95 - 6400 = 4483.95
Coinsurance (OON): 40% member = 0.40 * 4483.95 = 1793.58
Member responsibility = 6400 + 1793.58 = 8193.58
Plan paid = 10883.95 - 8193.58 = 2690.37
Check OOPM: C's OOPM before = 0. OON threshold = 14000. 0 < 14000, so not reached.
After: C OOPM = 0 + 8193.58 = 8193.58
C deductible: 0 + 6400 = 6400
C OOPM: 0 + 8193.58 = 8193.58
Family deductible: 74.87 + 6400 = 6474.87
Family OOPM: 74.87 + 8193.58 = 8268.45
**Line 3 — Claim 3 — C — Diagnostic laboratory panel, OON — Allowed: 967.99**
OON. Not preventive.
C's deductible balance = 6400. OON individual remainder = 6400 - 6400 = 0.
deductible_applied = min(967.99, 0) = 0
Remaining = 967.99
Coinsurance (OON): 40% = 0.40 * 967.99 = 387.196 → 387.20
Member responsibility = 0 + 387.20 = 387.20
Plan paid = 967.99 - 387.20 = 580.79
C OOPM before: 8193.58. Check OOPM: 8193.58 < 14000, not reached.
After: C OOPM = 8193.58 + 387.20 = 8580.78
C deductible: 6400 + 0 = 6400
C OOPM: 8193.58 + 387.20 = 8580.78
Family deductible: 6474.87 + 0 = 6474.87
Family OOPM: 8268.45 + 387.20 = 8655.65
**Line 4 — Claim 4 — A — Urgent care visit, in-network — Allowed: 255.34**
In-network. Not preventive.
Family deductible total = 6474.87. Family remainder = 6400 - 6474.87 = -74.87 → 0 (already met)
deductible_applied = min(255.34, 0) = 0
Remaining = 255.34
Coinsurance (in-network): 10% = 0.10 * 255.34 = 25.534 → 25.53
Member responsibility = 0 + 25.53 = 25.53
Plan paid = 255.34 - 25.53 = 229.81
A OOPM before: 74.87. In-network threshold: 7000. 74.87 < 7000, not reached.
Family OOPM: 8655.65 < 14000, not reached.
After: A OOPM = 74.87 + 25.53 = 100.40
A deductible: 74.87 + 0 = 74.87
A OOPM: 74.87 + 25.53 = 100.40
Family deductible: 6474.87 + 0 = 6474.87
Family OOPM: 8655.65 + 25.53 = 8681.18
**Line 5 — Claim 5 — A — Emergency department visit, in-network — Allowed: 3545.18**
In-network. Not preventive.
Family deductible total = 6474.87 >= 6400, so deductible met.
deductible_applied = 0
Remaining = 3545.18
Coinsurance: 10% = 0.10 * 3545.18 = 354.518 → 354.52
Member responsibility = 354.52
json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Claude Sonnet 4.6 · Anthropic277.6s · 22,683 out | 231.6s · 18,331 out | 165.7s · 15,255 out
Reasoning · 22,211 tokens
Let me carefully process each claim in order, tracking accumulators for each member and the family.
**Plan Details:**
- Deductible: AGGREGATE structure
- Family deductible: 6400.00 (in-network)
- No individual deductible threshold (aggregate structure - plan pays no coinsurance for ANY member until family total reaches 6400.00)
- Out-of-network individual deductible: 6400.00
- Single deductible balance (in-network and out-of-network credits accumulate to the same balance)
- OOPM:
- Individual (in-network): 7000.00, Family: 14000.00
- Individual (out-of-network): 14000.00
- Coinsurance after deductible: 10% member / 90% plan in-network, 40% member / 60% plan out-of-network, no copays
- Preventive in-network: no cost share, no accumulator movement; out-of-network preventive is subject to OON deductible and coinsurance
I'm re-reading the aggregate deductible rules to confirm how credits accumulate to a single member balance, and how the accumulator logic determines which threshold applies for in-network versus out-of-network services.
For in-network claims under AGGREGATE, the deductible applied is the smaller of the allowed amount and the family remainder. For out-of-network claims, it's the smaller of the allowed amount and the out-of-network individual remainder (6400.00), since out-of-network claims are only measured against the out-of-network individual threshold, not the family amounts. This same logic extends to the coinsurance trigger: in-network coinsurance starts once the family deductible is satisfied, while out-of-network coinsurance starts once that member's individual OON deductible (also 6400.00) is satisfied.
Turning to the OOPM rules, out-of-network claims only count against the individual OON OOPM threshold (14000.00), not the family OOPM (14000.00), even though the credits generated still flow into the family balance. So the family OOPM doesn't cap or limit an OON claim, but it still tracks the accumulated credits from OON activity in the background.
I'm now working through the actual claim-processing logic step by step: determine network status first, then apply the appropriate deductible (family aggregate for in-network, individual 6400.00 threshold for out-of-network), then apply coinsurance (10% in-network, 40% out-of-network) once the deductible is satisfied, then check against the correct OOPM ceiling (7000/14000 individual, 14000 family for in-network only). It seems like each member likely has a single combined deductible balance that both in-network and out-of-network claims draw from, just measured against different thresholds depending on claim type.
I'm setting up trackers for each member's deductible and OOPM balances, plus the family-level totals, before starting to process claims one by one from the first line item.
For claim 1, since the family deductible hasn't been met yet, A pays the full allowed amount toward deductible with no coinsurance, staying well under the OOPM cap, so I update A's and the family's deductible/OOPM balances to 74.87.
Now I'm moving to claim 2 for C, an out-of-network inpatient admission, and checking C's remaining out-of-network deductible threshold before calculating how much applies.
The 6400.00 deductible for C gets applied first, then the remaining balance splits with 40% coinsurance to the member, totaling 8193.58 in member responsibility -- well within C's individual OON OOPM cap of 14000.00, and I confirm the plan's family accumulators don't limit OON claims. I calculate plan_paid as 2690.37 and update C's and the family's running totals accordingly.
For claim 2, member owes 1793.58 in coinsurance on the remaining 4483.95, bringing C's total responsibility to 8193.58 and plan payment to 2690.37, which stays under the 14000.00 OOPM cap, so I update C's deductible to 6400.00 and OOPM to 8193.58, with family totals at 6474.87 and 8268.45.
For claim 3, C's deductible is already fully met, so the full 40% coinsurance applies to the 967.99 allowed amount, giving member responsibility of 387.20 and plan payment of 580.79, still well under the OOPM cap.
Moving to claims 4 and 5 for subscriber A, since the family deductible of 6474.87 has now exceeded the 6400.00 threshold, it's fully met—so in-network coinsurance at 10% kicks in for A's urgent care visit (255.34 allowed, 25.53 member share, 229.81 plan paid), and I'm now working through the emergency department visit with the same met-deductible logic applying.
For claim 5 at 3545.18 allowed, 10% coinsurance comes to 354.52 member responsibility, with A's OOPM rising to 454.92 and family OOPM to 9035.70, both still well under caps. Now I'm starting claim 6, an allergy testing visit at 911.89 allowed, again with the family deductible met so coinsurance calculating out to 91.19 member share.
Checking OOPM caps confirms A's total climbing to 546.11 and family to 9126.89, both still fine, so plan pays 820.70 on this claim and I update the running accumulators. Now I'm moving to claim 7, an ambulatory surgery for spouse B at 7845.50 allowed, with the family deductible already satisfied so I'm calculating the 10% coinsurance share on this larger claim.
Working through B's coinsurance to 784.55, checking it against OOPM caps (both individual and family stay under limit), then updating B's and the family's running totals before moving to claim 8 for child D — another ambulatory surgery at 6750.63 allowed, deductible already met, calculating the 10% coinsurance amount now.
Same process for D's claim: coinsurance comes to 675.06, no OOPM caps triggered, updating accumulators. Family OOPM now sits at 10586.50. Moving into claim 9 for spouse B, an inpatient admission with allowed amount 12250.27, deductible satisfied, now computing the 10% member coinsurance share.
B updates to oopm 2009.58; family deductible 6474.87, family oopm 11811.53.
Moving to claim 10 for D (child), in-network inpatient admission with allowed amount 12224.51. Family deductible is already met, so I'm checking OOPM status next.
With the deductible not applying, coinsurance is 10% member share on 12224.51, which comes to 1222.45. Checking D's individual OOPM (675.06 + 1222.45 = 1897.51, well under the 7000 cap) and the family OOPM (11811.53 + 1222.45 = 13033.98, under the 14000 cap) confirms neither cap is triggered. So member owes 1222.45 and the plan pays 11002.06.
I'm updating the accumulators: D's deductible resets to 0, OOPM climbs to 1897.51, and family deductible sits at 6474.87 with OOPM at 13033.98.
Moving to claim 11 for D, an out-of-network annual wellness visit allowed at 664.62. I need to check whether this counts as preventive care, since the plan's language about preventive services being covered at 100% specifically applies to in-network services.
I'm confirming that out-of-network preventive services are still subject to the OON deductible and coinsurance, so this claim needs standard cost-sharing applied. D's OON deductible balance is 0 out of a 6400 threshold, so I'm applying the deductible against the full 664.62 allowed amount.
Since D's remaining OON balance (664.62) stays below the 6400 threshold, no coinsurance kicks in yet since coinsurance only applies once the deductible is fully met.
So the full 664.62 counts toward deductible, leaving member responsibility at 664.62 and plan paid at 0.00.
Checking D's OON individual OOPM cap of 14000.00: current OOPM is 1897.51, plus 664.62 brings it to 2562.13, well under the cap so no adjustment needed. I'm updating both D's individual accumulators and the family totals accordingly - D's deductible and OOPM now stand at 664.62 and 2562.13, while the family deductible reaches 7139.49 and family OOPM hits 13698.60.
Actually D's deductible balance was 0 before line 11, since lines 8-10 were coinsurance after the family deductible was met, not deductible credits. So after line 11, D's deductible balance becomes 664.62.
Family deductible balance now totals 6474.87 + 664.62 = 7139.49.
Moving to line 12, claim 12 for spouse B, out-of-network, allowed amount 30.19 for a generic retail pharmacy fill. B's deductible balance is 0 against an OON threshold of 6400.00, so the full 30.19 applies to deductible with nothing left over for coinsurance — member responsibility is 30.19, plan pays nothing. Checking B's OOPM (OON individual cap 14000.00): current 2009.58 plus 30.19 equals 2039.77, well under the cap, so no adjustment needed there. Now I'm updating the accumulators for this claim.
For line 13, claim 13 involves child D getting a screening colonoscopy out-of-network with an allowed amount of 716.51. I'm considering whether this counts as preventive since no polyp was removed, but since it's out-of-network, the plan rules state OON preventive services still go through the standard OON deductible and coinsurance process rather than being covered at 100%. So I need to apply this against D's deductible balance of 664.62 within the 6400.00 OON threshold.
The full deductible amount of 716.51 gets applied since it's less than D's remaining deductible room of 5735.38, bringing D's deductible balance to 1381.13, which stays below the OON coinsurance threshold so no coinsurance kicks in. This means member responsibility is the full 716.51 with zero plan payment, and checking against D's OON individual OOPM cap of 14000.00, the running total of 3278.64 stays well under the cap. I'm updating both D's and the family's deductible and OOPM accumulators accordingly.
Now I'm reconsidering whether the family OOPM threshold applies here — re-reading the plan rules, OON claims are only measured against the OON individual thresholds, not the family amounts (which are in-network specific), though the credits still flow into the family balance for tracking purposes even though they don't cap the OON claim itself. So I'll update the family OOPM to 14445.30, noting this exceeds 14000.00, which matters for future in-network claims since once family OOPM is met, in-network claims would be paid at 100%.
So yes, the family OOPM balance is explicitly stated to accumulate from OON credits too, and since it's now 14445.30, exceeding the 14000.00 in-network family threshold, in-network claims would be paid at 100% for all family members going forward, even though individual OON OOPM tracking remains separate.
D's OON OOPM is 14000.00, still unmet before Line 13; after it, D's OOPM reaches 3278.64 and family OOPM hits 14445.30, confirming the family threshold is exceeded.
Now moving to Line 14, voiding Claim 3 for C: since no deductible was applied on that claim, I only need to reverse C's OOPM credit of 387.20.
Removing that credit from both C's and the family's OOPM totals, I get C's OOPM at 8193.58 while C's deductible stays at 6400.00, and the family deductible remains 7886.19 while I work out the updated family OOPM after backing out the 387.20.
Family OOPM comes to 14058.10, still above the 14000.00 threshold, so family OOPM stays met.
Moving to claim 15 for A on an out-of-network endoscopy allowed at 2331.25, I calculate the OON deductible remainder against A's current balance of 74.87 and apply the full amount since it's under the 6400.00 threshold, bringing A's deductible balance to 2406.12, still below the individual OON limit.
Since OON coinsurance is 0.00, the full 2331.25 becomes member responsibility with no plan payment. Checking A's OOPM against the 14000.00 individual OON cap, I track A's running total through line 6 at 546.11, confirm lines 7-14 didn't affect A, then add this claim's 2331.25 to get 2877.36 — well under the cap, so no OOPM limiting applies, and family OOPM remains above threshold too.
The plan explicitly states family in-network amounts don't limit OON claims, so only A's individual OON OOPM matters. I finalize member_responsibility=2331.25, plan_paid=0.00, and update A's deductible to 2406.12 and OOPM to 2877.36, with family deductible now at 10217.44 and family OOPM at 16389.35. Now moving to line 16, which is a void of claim 6 for A, an in-network claim with allowed amount 911.89.
Voiding claim 6 removes its OOPM credit of 91.19 from both A and the family, bringing A's OOPM down to 2786.17 and family OOPM to 16298.16, while deductibles stay unchanged since none applied. I then move to line 17, claim 17 for E involving out-of-network physical therapy with an allowed amount of 1373.69, checking E's deductible balance of 0.00 and OON threshold of 6400.00 to calculate the deductible applied.
The full 1373.69 goes to E's deductible since it's under the threshold, leaving no coinsurance and making plan_paid zero with member_responsibility equal to the full 1373.69. I verify this doesn't trigger E's OOPM cap of 14000.00, then update E's accumulators to ded=1373.69, oopm=1373.69, and roll the family totals forward to ded=11591.13, oopm=17671.85 before moving to claim 18 for C.
For this diagnostic lab panel, C's deductible balance already equals the OON threshold of 6400.00, so no additional deductible applies and the full 40% coinsurance kicks in — 237.28 on the 593.21 allowed amount. Checking against C's OOPM cap confirms no limit is hit, so member_responsibility is 237.28 and plan_paid is 355.93, and I'm updating C's and the family's deductible/OOPM accumulators accordingly.
Moving to claim 19 for B's urgent care visit in-network: family deductible is already met, and the family OOPM balance now exceeds 14000.00, meaning the family OOPM is satisfied and the plan should pay 100% in-network. I want to double-check B's individual OOPM too before finalizing that the member owes nothing.
Confirmed, family OOPM is 17909.13, well above the 14000.00 threshold, so it was already met before Line 19. Since all credits including out-of-network responsibility accumulate to the family balance, and once a member's family reaches the OOPM the plan pays 100% for covered in-network services, this should apply to B's claim.
Tracking the family OOPM through subsequent lines - it stays well above 14000.00 even after voids, confirming for Line 19 (member B, in-network) the plan pays 100% since family OOPM is met, regardless of B's individual OOPM status. This gives member_responsibility = 0.00 and plan_paid = 220.46, and I'm updating the running accumulators for B and the family accordingly.
For Line 20 (member A, routine immunization), this is a preventive service paid at 100% in-network with no accumulator movement, so plan_paid = 1243.12 with zero cost-share.
For Line 21 (member C, emergency department visit), family OOPM remains satisfied so plan pays 100% again, giving plan_paid = 3516.29 with no OOPM change, and I'm noting the accumulator update for C.
Family OOPM stays well above the 14000.00 threshold, so Line 22 (member E, inpatient admission) is also paid at 100% with plan_paid = 12475.02 and no accumulator changes.
Now I'm moving into Line 23, an adjustment to Claim 20, reviewing that the original claim was member A's in-network preventive routine immunization service.
Since the original allowed amount was correct at 0 member cost, there are no credits to unwind. I'm re-adjudicating at the corrected allowed amount of 745.87, and since routine immunization remains preventive, it's still covered at 100% with zero deductible or coinsurance applied.
Moving to claims 24 and 25 for member D — both in-network services with family OOPM already well above 14000.00, so the plan pays 100% with no member responsibility or accumulator changes on either line.
Now I want to compile all the final accumulators, but I realize I should retrace the whole calculation from the start to make sure everything lines up correctly.
Starting all members and family at zero deductible and out-of-pocket, I begin processing claim 1 for member A: an in-network pharmacy claim with an allowed amount of 74.87. Since the family deductible hasn't been met yet, I apply the deductible against this claim and the member pays the full allowed amount toward it.
Checking A's OOPM (74.87) against the individual limit of 7000 and the family OOPM against 14000, both remain well within bounds, so the full 74.87 counts as member responsibility with no plan payment. I update A and the family totals to reflect deductible and OOPM of 74.87 each, then move on to claim 2 for member C, an out-of-network claim.
For C's out-of-network claim of 10883.95, I apply the remaining OON deductible of 6400.00, then calculate 40% coinsurance on the remaining 4483.95, giving 1793.58. Checking C's individual OOPM of 8193.58 against the 14000 OON cap, it's still under the limit, so I'm now looking at whether the family OOPM applies for out-of-network claims.
Since family amounts don't limit OON claims individually, I'm tallying up member and plan responsibility: 8193.58 to the member and 2690.37 paid by the plan. Updating running totals, C's deductible hits 6400.00 and OOPM reaches 8193.58, while the family deductible climbs to 6474.87 — which crosses the 6400.00 threshold, meaning the family deductible is now fully met. Moving to claim 3 for C at 967.99, I note that C's OON deductible balance already equals the threshold, so it's satisfied for this next claim.
For claim 3, since C's OON deductible is met, I calculate the coinsurance at 40% of the allowed amount, rounding to 387.20, and confirm the OOPM cap isn't triggered since it stays under 14000.00. This makes member responsibility 387.20 and plan payment 580.79, updating C's OOPM to 8580.78 and the family OOPM to 8655.65. Now for claim 4 on member A, since the family deductible is already met at 6474.87, no further deductible applies, and I need to work out the in-network coinsurance rate that applies now.
For claim 5, family deductible is already met, so deductible_applied = 0.00. Coinsurance is 10% × 3545.18 = 354.52, and checking OOPM caps, A's total reaches 454.92 and family reaches 9035.70, both still under their respective limits so no cap applies.
Moving to claim 6, allowed amount 911.89, deductible still met so no deductible applies. Coinsurance comes to 91.19, bringing A's OOPM to 546.11 and family OOPM to 9126.89, both remaining under the caps.
Now onto claim 7 for member B, allowed amount 7845.50, deductible met, coinsurance calculates to 784.55. Checking OOPM caps: B's individual total reaches 784.55, well under 7000, and I'm updating the family OOPM total to reflect this addition.
Moving to claim 8 for member D at an allowed amount of 6750.63, deductible already satisfied, so I'm computing 10% coinsurance and comparing against D's individual out-of-pocket max.
Both individual and family OOPM remain under their caps, so I finalize claim 8: plan pays 6075.57, member owes 675.06 in coinsurance. Family totals now stand at ded=6474.87, oopm=10586.50, and I'm moving on to claim 9 for member B.
For claim 9, since family deductible is already satisfied, I calculate 10% coinsurance on the 12250.27 allowed amount, giving 1225.03. Checking this against B's individual OOPM cap and the family OOPM cap, both remain well under their limits, so no capping applies — plan pays 11025.24, member owes 1225.03. Updated running totals: B's oopm=2009.58, family ded=6474.87, oopm=11811.53.
Now moving to claim 10 for D, in-network with allowed amount 12224.51. Family deductible remains met, so coinsurance is again 10%, coming to 1222.45. D's OOPM reaches 1897.51 and family OOPM reaches 13033.98, both still under caps, so plan pays 11002.06 and member owes 1222.45.
Next up is claim 11 for D, out-of-network annual wellness visit with allowed amount 664.62. Since it's preventive but out-of-network, it's subject to the OON deductible rather than being fully covered — D's OON remaining is 6400.00, so the full 664.62 applies to deductible, leaving the balance at 664.62.
No coinsurance applies since it's all going toward deductible. Checking OOPM for D against the 14000.00 individual OON limit, 2562.13 stays well under the cap, so member responsibility is the fulljson{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.13",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 17,858 tokens
Let me work through this carefully, line by line, tracking accumulators for each member and the family.
**Plan Structure:**
- AGGREGATE deductible: Family must hit $6400.00 before any member gets coinsurance
- Individual deductible threshold: $3200.00 (but this only matters for... wait, let me re-read)
Wait, re-reading the plan:
- Structure: AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure.
- So the aggregate family deductible is $6400.00
- Out-of-network individual deductible: $6400.00
I'm working out how deductible amounts get applied differently for in-network versus out-of-network claims — in-network claims draw against the shared family remainder, while out-of-network claims draw against each member's own $6400.00 individual balance. I'm now re-checking the accumulator rules to confirm exactly how the lesser-of comparison should be calculated for each case.
Given the aggregate structure here, in-network claims only look at the family remainder, while out-of-network claims check the member's single deductible balance against the $6400 OON threshold, since both types of credits feed into that same member balance. The family amounts don't constrain out-of-network claims at all — only the out-of-network individual threshold applies there.
I'm also noting the OOPM levels ($7000/$14000 in-network individual/family, $14000 OON individual), the post-deductible cost shares (10/90 in-network, 40/60 out-of-network), and that there are no copays. In-network preventive care has zero cost share and doesn't touch accumulators, but out-of-network preventive care is still subject to the OON deductible and coinsurance.
Now I'm working through each claim line starting from zero balances for everyone. For claim 1 (subscriber A, generic retail pharmacy, in-network, $74.87 allowed), since this is aggregate family deductible tracking and the family hasn't met deductible yet, the full $74.87 applies toward deductible and is paid entirely by the member, with the plan paying $0 and A's OOPM increasing by that amount.
Moving to claim 2 for the child C, an out-of-network inpatient admission with $10,883.95 allowed, I'm applying the individual OON deductible threshold of $6400 since C's deductible balance is still zero, leaving $4483.95 remaining after the deductible is exhausted.
Applying 40% OON coinsurance on the remainder gives $1793.58, so member responsibility totals $8193.58 — checking this against C's individual OON OOPM of $14,000 confirms it doesn't hit the cap, so plan pays $2690.37. I'm updating C's and the family's accumulators accordingly, but now I need to think through whether this plan uses an embedded or aggregate deductible/OOPM structure for the family calculation.
Since the claim is OON, I need to re-examine the rule that OON claims are measured only against OON individual thresholds, not family amounts — though the credits generated still flow into the family balance. So C's deductible threshold here is the $6400 individual OON amount, and since C started at $0, the full $6400 applies toward that threshold.
This raises the question of whether C hitting their OON deductible also satisfies the family deductible, since the family balance reached $6474.87 against the $6400 in-network family threshold — meaning the family deductible is now met for future in-network claims, even though each member still must independently satisfy their own $6400 OON threshold for future out-of-network claims.
For Line 3, C's diagnostic lab panel is out-of-network with $967.99 allowed. Since C's deductible balance already sits at $6400 (matching the OON threshold), no further deductible applies here — the full amount goes to 40% coinsurance, meaning C owes $387.20 and the plan pays $580.79, pushing C's OOPM to $8580.78.
Now updating accumulators: C's deductible stays at $6400, C's OOPM rises to $8580.78, family deductible reaches $6474.87, and family OOPM climbs to $8655.65.
For Line 4, A's urgent care visit ($255.34 allowed, in-network) hits a family deductible that's already satisfied, so the full amount goes to 10% coinsurance — $25.53 owed by A, $229.81 paid by the plan, bringing A's OOPM to $100.40, well under the $7000 individual cap.
For Line 5, A's ER visit ($3545.18 allowed) also falls under the met family deductible, so coinsurance applies again: $354.52 owed by A, $3190.66 paid by the plan, pushing A's OOPM to $454.92 and family OOPM to $9035.70. Now moving to Line 6, A's allergy testing claim, still in-network.
I calculate the allergy testing at 10% coinsurance: $91.19 owed by A, $820.70 paid by the plan, bringing A's OOPM to $546.11 and family OOPM to $9126.89. Then I start on Line 7, an ambulatory surgery claim for B, the spouse, in-network.
Applying 10% coinsurance on $7845.50 gives $784.55 owed by B, which stays under both individual and family OOPM caps, so the plan pays $7060.95 and I update B's OOPM to $784.55 and family OOPM to $9911.44. Now I'm moving to Line 8, another claim for D.
For D's ambulatory surgery at $6750.63 allowed, family deductible is already met, so applying 10% coinsurance gives $675.06 owed by D — well under D's individual OOPM and pushing family OOPM to $10586.50, still under the $14000 cap. Plan pays $6075.57, and I update D's OOPM to $675.06 while family deductible stays at $6474.87.
Moving to claim 9 for B's inpatient admission at $12250.27 allowed, again deductible is satisfied so I apply 10% coinsurance = $1225.03 owed by B. Checking B's individual OOPM brings it to $2009.58 and family OOPM to $11811.53, both still under their caps, so plan pays $11025.24 and I'm updating B's accumulators accordingly.
For claim 10, D's inpatient admission at $12224.51 allowed similarly hits the 10% coinsurance rate since deductible is met, giving $1222.45 owed. D's individual OOPM rises to $1897.51 and family OOPM to $13033.98, both still within limits, so plan pays $11002.06 and I update D's and the family's totals. Now moving to claim 11 for D's annual wellness visit.
Since this wellness visit is out-of-network at $664.62 allowed, I note that OON preventive services aren't covered at 100% like in-network ones — they're subject to the OON deductible and coinsurance. D's OON deductible balance is still at zero with $6400 room, so the full $664.62 applies toward deductible without yet satisfying it.
So the member owes the full $664.62, plan pays nothing. Checking D's OOPM: 1897.51 + 664.62 = 2562.13, still well under the $14000 OON threshold. I update D's running deductible to 664.62 and OOPM to 2562.13, and roll the family totals forward accordingly.
Moving to claim 12, B's generic retail pharmacy fill out-of-network for $30.19 — B's deductible balance is also at zero.
Since B hasn't met the $6400 OON threshold either, the full $30.19 applies to deductible and becomes member responsibility, with plan paying nothing. B's OOPM moves to 2039.77, still far under 14000, and I update both B's and the family's running totals.
Now looking at claim 13, D's screening colonoscopy out-of-network for $716.51 — I need to consider whether this counts as preventive care despite being out-of-network, which would change how it's processed.
Rereading the rules, OON preventive services still carry cost-sharing subject to deductible and coinsurance. D's deductible balance sits at 664.62 against the $6400 threshold, so the full $716.51 applies toward deductible, bringing D to 1381.13 — still below the threshold, meaning member pays the full allowed amount and plan pays zero. D's OOPM rises to 3278.64, well under 14000, so I'm updating the accumulators accordingly.
But this pushes family OOPM to 14445.30, exceeding the stated 14000 family maximum. I recall the plan specifies that OON claims measure against individual OON thresholds only, and family in-network amounts don't cap or limit an OON claim — though the dollars still credit to the family balance. So exceeding the nominal family OOPM figure doesn't actually change how this claim is processed.
The threshold got crossed mid-claim, with the full $716.51 applied and family OOPM rising from 13728.79 to 14445.30. But since family in-network amounts don't limit an out-of-network claim, D's claim is bounded by D's individual OON OOPM of $14000, and D's balance sits at 3278.64, well under that cap — so D pays the full $716.51 as deductible. Let me double check this reasoning though.
So D's OON claim isn't capped by family OOPM and D pays the full 716.51, which still credits toward the family OOPM: 13728.79 + 716.51 = 14445.30, exceeding the 14000 threshold. That raises the question of whether this overage should trigger 100% coverage on future in-network claims, or whether the 445.30 excess needs to be handled differently since it came from an OON claim not meant to be limited by the family OOPM in the first place.
For each OON claim after this I need to check the individual member's OON OOPM of 14000 rather than the family accumulator.
After updating the totals for line 13, I see A, B, C, D, and E each have their own deductible and OOPM balances, with the family deductible at 7886.19 and family OOPM at 14445.30.
Now I'm moving to line 14, which voids C's earlier diagnostic laboratory panel claim (claim 3, OON), so I need to reverse those components from C's and the family's totals.
Rechecking claim 3's math: since C's OON deductible was already exhausted by claim 2, the deductible_applied was 0.00, meaning the full billed amount flowed straight into coinsurance, producing a 387.20 member responsibility and 580.79 plan paid. Voiding this claim means removing that 387.20 from C's OOPM without touching C's deductible, since no deductible credit was applied in the first place.
Now updating the family totals to remove that same 387.20 from the family OOPM, leaving deductible unchanged there too. After processing line 14, I have the updated balances: A at 74.87 deductible/546.11 OOPM, B at 30.19/2039.77, C at 6400.00/8193.58, D at 1381.13/3278.64, E at 0/0, and the family combined at 7886.19 deductible and 14058.10 OOPM.
Moving to line 15, claim 15 for subscriber A—an out-of-network outpatient endoscopy with an allowed amount of 2331.25. I need to check A's remaining OON deductible balance before applying coinsurance.
The OON individual deductible threshold is 6400.00, so with A's balance at 74.87, there's room for 6325.13 of deductible, meaning the full 2331.25 goes toward deductible with none left over for coinsurance. This brings A's OON deductible to 2406.12, still under the 6400 threshold, so the entire allowed amount becomes member responsibility with the plan paying nothing. I check A's OOPM against the 14000 OON individual limit and confirm it's still under at 2877.36, and I note that even though the family OOPM has already exceeded 14000, that's an in-network accumulation that doesn't cap this out-of-network claim. I update A's deductible to 2406.12 and OOPM to 2877.36, and add the same amount to the family deductible total, bringing it to 10217.44.
Now I'm processing the void of Claim 6, A's in-network allergy testing claim, which requires removing the previously applied credits: since that claim had zero deductible applied (family deductible was already met) and 91.19 in coinsurance responsibility, I subtract 91.19 from both A's OOPM and the family OOPM, bringing A's OOPM down to 2786.17.
Then I move to Line 17, Claim 17 for E, an out-of-network physical therapy claim with an allowed amount of 1373.69. Since E's OON deductible balance is still 0.00 against a 6400.00 threshold, the full 1373.69 gets applied to deductible and becomes E's member responsibility, and checking against the 14000 OON individual OOPM threshold, this keeps E well under the limit.
No plan payment occurs since it all goes to deductible. I update E's running totals to 1373.69 for both deductible and OOPM, and the family accumulators climb to 11591.13 deductible and 17671.85 OOPM. Then I move on to Line 18, Claim 18 for C — an out-of-network diagnostic lab panel with an allowed amount of 593.21, checking C's remaining deductible balance which is now at the 6400.00 OON threshold.
Moving to line 19, claim for B's urgent care visit at 220.46 allowed, in-network. The family deductible is already met (11591.13 exceeds 6400.00), so no deductible applies here and the 10% member coinsurance kicks in—now I need to check B's individual OOPM against this new charge.
Since the family OOPM has already been exceeded (17909.13 ≥ 14000.00), that changes things: for in-network claims once the family OOPM is met, the plan should pay 100%, making member responsibility 0.00 and plan_paid the full 220.46. I'm pausing to think through whether hitting the family OOPM caps out cost-sharing for all family members regardless of their individual OOPM status.
But the family OOPM itself seems to be an in-network only threshold, so I need to check whether OON claims can actually trigger it being met—the plan language suggests out-of-network claims are measured against separate OON thresholds, not the in-network family amount, which complicates whether Line 13 actually crossed the 14000 family OOPM.
Tracing the numbers: after Line 12, family OOPM sits at 13728.79, needing just 271.21 more to hit 14000, which D's OON deductible payment during Line 13 would supply.
Since it's an OON claim, D still pays the full 716.51 regardless of the family cap, bringing family OOPM to 14445.30—exceeding the 14000 threshold. Once family OOPM is met, I believe all family members' subsequent in-network claims should have member responsibility drop to zero, since the plan pays 100% of allowed amounts after the OOPM is reached.
But then I need to track how the void of Claim 3 pulls family OOPM back down to 14058.10—still above 14000, so it stays met—before Claim 6's void and A's OON endoscopy claim push the numbers further, which I'm recalculating step by step.
Now checking exactly when family OOPM crosses 14000: it happens during Line 13, but since that's an OON claim exempt from family-limit reduction, I need to figure out whether the crossing still applies to the subsequent voided claim on Line 14.
After voiding Claim 3, family OOPM drops to 14058.10, still above 14000, and stays above threshold through Line 16 too. Since family OOPM stays met from Line 14 onward, I'm now checking whether Line 19's in-network claim benefits from the family limit already being satisfied.
Family OOPM is met, so the plan pays 100% for B's in-network claim regardless of B's individual OOPM status (2039.77, below the 7000 individual limit) — member responsibility is zero, plan pays the full $220.46 allowed amount, with no deductible, coinsurance, or copay applied. The plan language confirms this applies once either the individual or family OOPM is reached.
Since the family OOPM is already met, this claim doesn't change the family accumulator. I update the running totals for all members after Line 19, then move to Line 20 for A's routine immunization claim, allowed at 1243.12, noting it's a preventive service that should typically be covered without cost-sharing in-network.
Applying that logic: member responsibility is 0, plan pays the full 1243.12, and no accumulators move since it's preventive care. I note this is the original Claim 20 that will need to be adjusted later.
Moving to Claim 21, C's ED visit for 3516.29 hits both family deductible and OOPM already met, so plan pays it all with no accumulator changes. Claim 22, E's inpatient admission at 12475.02, works the same way — family deductible and OOPM already satisfied, plan pays in full, accumulators stay unchanged.
Now I need to correct Claim 20, A's immunization, since the original allowed amount was wrong. I void the original preventive claim (which had zero cost-share) and reprocess it at the corrected allowed amount of 745.87 — still preventive, so member responsibility stays zero and plan pays the full corrected amount, with no accumulator changes either way.
Then moving to Line 24 (D's primary care visit, allowed 201.22) and Line 25 (D's physical therapy, allowed 1508.35) — both in-network with family deductible and OOPM already met, so both are fully plan-paid with zero member responsibility and no accumulator changes.
Now I'm compiling the final answer set for each claim, starting with claim 19's urgent care visit (fully plan-paid at 220.46 since OOPM is met) and moving into claim 20's adjusted immunization amount under in-network preventive coverage.
Then I finalize claim 25 (D's physical therapy, fully plan-paid at 1508.35) and record the ending accumulator totals across all members and the family.
I want to double-check line 2, C's inpatient out-of-network claim — recalculating the deductible application at 6400, the remaining allowed amount split at 40% coinsurance, and verifying how this pushes C's OON OOPM total up to 8193.58 against the OON individual limit.
Verifying continues through line 3 (C's OON lab) applying remaining coinsurance since the deductible room is exhausted, then confirming lines 4 and 5 for A's urgent care and ED claims, where the family deductible is already met and only the 10% in-network coinsurance applies.
10%×12224.51 = 1222.45 ✓ Now let me reconsider Lines 7-10 against the family OOPM tracking: at Line 7 family OOPM hits 9126.89, still below the 14000 threshold, and at Line 8 it reaches 9911.44, still under.
Continuing through Lines 9 and 10, family OOPM climbs to 10586.50 then 11811.53 then 13033.98 -- all still under the 14000 cap, so the threshold hasn't been crossed yet through Line 10. Now I need to check what happens at Line 11.
Continuing through Lines 11-13, family OOPM rises to 13698.60, then 13728.79, then crosses over to 14445.30 at Line 13 -- exceeding the 14000 cap. But since Line 13 is an out-of-network claim, the family limit doesn't apply to it, so I need to figure out how that affects D's cost-sharing here.
Now I'm considering whether hitting this threshold means later in-network claims get zero member responsibility, checking Line 14 (a void) and Line 15 (also out-of-network) to see if the cap actually kicks in anywhere.
By Line 19, B's urgent care visit is in-network and the family total has grown to 17909.13, well past the 14000 threshold, so I'm reasoning that B's coinsurance should drop to zero here instead of the normal 10% share. I want to double-check this against the plan's actual family out-of-pocket maximum language before finalizing that assumption.
For all lines in this bucket member_responsibility becomes 0, even though B individually hasn't reached their own $7000 in-network OOPM (balance only 2039.77) — the family OOPM being met is enough to trigger full plan coverage. Line 20, A's routine immunization, is preventive so it's fully covered with no cost share and no accumulator impact. Then Line 23 needs to reverse the earlier Claim 20 entry by removing its deductible contribution.
Re-adjudicating Claim 20 at allowed 745.87, it's still preventive/in-network, so member_responsibility stays 0.00, plan_paid becomes 745.87, and no accumulators change — same for Claim 25, D's physical therapy, where family deductible and OOPM are both already met, so it's fully plan-paid at 1508.35 with zero member cost.
Now tallying A's final accumulators across all 25 lines: deductible credited from Claim 1 (74.87) and Claim 15 (2331.25) totals 2406.12, while OOPM sums contributions from Claims 1, 4, 5, 6, 15, and the adjusted Claim 20 (which adds nothing since it's preventive), then subtracts back the 91.19 from the voided Claim 6, landing at 2786.
Verifying that OOPM sum step by step confirms 2786.17.
Moving to B's totals: deductible comes only from Claim 12 (30.19), and OOPM sums Claims 7, 9, and 12 to reach 2039.77, which I double-check and confirm.
Now starting C's accumulatiojson{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.13",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 14,783 tokens
Let me carefully process each claim in order, tracking accumulators for each member and the family.
**Plan Details:**
- Structure: AGGREGATE — no coinsurance for any member until total family credits reach family deductible of 6400.00
- In-network deductible: Family 6400.00 (aggregate)
- Out-of-network individual deductible: 6400.00 (measured against the member's single deductible balance)
- In-network individual OOPM: 7000.00
json{
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.13",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100GPT-5.6 Terra · OpenAI42.5s · 3,228 out | 35.2s · 2,872 out | 38.9s · 2,877 out
Reasoning · 2,829 tokens
**Considering member responsibility and deductibles**
I'm thinking about how to apply the member responsibility correctly. If 716 is applied alongside a 271 member responsibility contradiction, it seems deductibles need to be considered as well. The deductible actually should be a part of the member's overall cost. I need to apply out-of-pocket (OOP) expenses to the deductible, and I believe that the deductible applied should end up being around 271.21. I'm working through these numbers!
**Reviewing claims and adjustments**
I'm analyzing the values related to claims, looking at member totals and making sure they match with expectations. There’s a potential ambiguity regarding preventive services—like routine immunizations and screenings—that aren’t free outside of the network. Plus, there’s a question about whether family out-of-pocket costs may be capped.
I’m noting that contract details say dollar amounts should be plain numbers formatted to two decimal places for clarity in JSON. It’s important to get this right!json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 2,473 tokens
**Considering money formatting**
I'm thinking about how to handle money formatting requirements, especially needing two decimal places. It seems like JSON numbers might lose that visual precision, so maybe it’s better to use strings to keep it exact. I'm inferring that the expected format is something like "0.00." Since they're emphasizing amount formatting, using string values makes sense to ensure the decimal precision stays intact. That way, I can stick closely to the required standards!json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.13",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100GLM-5.3 Flash · Z.ai267.0s · 14,676 out | 256.1s · 14,321 out | 371.2s · 20,417 out
Reasoning · 14,276 tokens
Let me carefully work through this ledger.
Plan: Trinity HDHP 3200, plan year 2026.
Deductible:
- Individual (in-network): 3200.00
- Family (in-network): 6400.00
- Structure: AGGREGATE — plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure.
- Out-of-network (individual): 6400.00
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The out-of-network amount (6400) is the threshold that balance is measured against when the service is out-of-network.
OOPM:
- Individual (in-network): 7000.00
- Family (in-network): 14000.00
- Individual (out-of-network): 14000.00
- Once a member reaches OOPM, plan pays 100% for covered services for remainder of plan year.
Cost share:
- After deductible, in-network: 10% member / 90% plan
- After deductible, out-of-network: 40% member / 60% plan
- No copays.
Preventive: in-network preventive = paid 100%, no cost share, no deductible. Out-of-network preventive is subject to out-of-network deductible and coinsurance.
Accumulator rules:
- deductible_applied = LESSER of allowed amount and room left under the deductible threshold that applies:
- in-network: family remainder alone (aggregate)
- out-of-network: out-of-network individual remainder, measured against member's same single deductible balance.
- Once applicable threshold is met, deductible_applied = 0.00.
- Balance = running total of deductible_applied (deductible) or member_responsibility (OOPM).
- Out-of-network claims measured against out-of-network individual thresholds only; family amounts do not limit out-of-network claim. Credits still accumulate to member and family balances.
OOPM logic: Member OOP balance counts member_responsibility. The in-network individual OOPM is 7000; out-of-network individual OOPM is 14000. Family in-network OOPM is 14000. Hmm, there's no family out-of-network OOPM given... The plan document lists "Individual (out-of-network) 14000.00" and "Family (in-network) 14000.00". Presumably family out-of-network OOPM would be 28000 but not stated. The rules say "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim."
So for each claim, we need to determine:
1. Deductible applied: for in-network, min(allowed, family deductible remainder) where family threshold = 6400. For out-of-network, min(allowed, member's individual remainder against 6400 out-of-network threshold). Note "single member deductible balance" — the member's deductible balance is the same accumulation; the threshold depends on network: in-network claims measured against... wait, under aggregate structure, there is no individual deductible; in-network claims credit the family deductible. Out-of-network claims are measured against the out-of-network individual threshold (6400) using the member's single deductible balance.
Hmm, so a member's deductible balance may include both in-network credits (which count toward family) and out-of-network credits. Let me think about how the member's balance works.
The member's deductible balance = running total of deductible_applied for that member. Family deductible balance = running total of deductible_applied across all members.
In-network claim: threshold = family deductible 6400 (aggregate). Room = 6400 - family balance. deductible_applied = min(allowed, room).
Out-of-network claim: threshold = 6400 (out-of-network individual) measured against the member's single deductible balance. Room = 6400 - member's balance. deductible_applied = min(allowed, room).
Interesting: so member's balance includes in-network credits too. So if A has 3200 in-network deductible credits, then for an out-of-network claim, A's balance is 3200, room = 6400 - 3200 = 3200.
OOPM: member's OOP balance = running total of member_responsibility. For in-network claims, threshold = 7000 individual... but also family 14000? Hmm. The family OOPM (in-network) is 14000. Typically with embedded/family OOPM, a member's cost share stops when either individual or family OOPM is reached. The plan doc 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 rules mention: "the balances are not capped at the in-network amounts" — meaning out-of-network claims can push balances past the in-network individual amounts (7000 deductible... wait deductible in-network individual is 3200; OOPM individual in-network 7000). And "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim."
So for OOPM:
- In-network claim: measured against individual in-network OOPM (7000) and family in-network OOPM (14000)? The doc doesn't explicitly say family OOPM limits member's OOP. Hmm. Let's think.
Actually the doc says "Once a member reaches the out-of-pocket maximum the plan pays 100%..." — singular. The family OOPM of 14000 presumably applies such that when family total OOP reaches 14000, all members are at 100%. This is standard. But does the family OOPM cap a member's in-network cost share before the member individually reaches 7000? Standard: yes — once family OOPM is met, everyone is at 100%.
Let me compute and see whether family OOPM 14000 gets reached.
Also, the deductible portion: member responsibility includes deductible applied + coinsurance. Since deductible credits count toward OOP (standard; the doc says OOP balance = running total of member_responsibility, and member responsibility includes deductible amounts).
Let me now process line by line.
Initial: all deductible 0.00, OOP 0.00. Family deductible 0.00, family OOP 0.00.
Thresholds:
- In-network deductible: family 6400 (aggregate; no individual).
- Out-of-network deductible: individual 6400 (measured against member's single balance).
- In-network coinsurance: 10% member.
- Out-of-network coinsurance: 40% member.
OOPM: individual in-network 7000; individual out-of-network 14000; family in-network 14000.
Hmm, how do we handle OOPM for in-network claims? A member's OOP balance includes both in-network and out-of-network member responsibility. The threshold for an in-network claim... The member's OOP balance is single (like deductible). For in-network claims, does the family OOPM (14000) also limit? The glossary says OOPM is ceiling on member cost share for plan year; once reached plan pays 100% for covered in-network services. The plan doc 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."
Which OOPM applies to an in-network claim: individual in-network 7000, or family in-network 14000? Both presumably: if member's OOP balance reaches 7000, they're done; if family OOP balance reaches 14000, everyone's done (for in-network at least).
Actually wait — is family OOPM 14000 an in-network family amount? Yes. And is there a family out-of-network OOPM? Not stated. The rules say out-of-network claims are measured against out-of-network individual thresholds only.
So for in-network claims: member is at 100% if member's OOP balance >= 7000 (individual in-network) OR family OOP balance >= 14000 (family in-network). Hmm, but careful: member's OOP balance might exceed 7000 due to out-of-network claims (since out-of-network OOPM is 14000). If a member's balance is 8000 all from out-of-network claims, is the member at their in-network OOPM? Their single balance is 8000 >= 7000... The rule "balances are not capped at the in-network amounts" suggests the balance keeps accumulating; but does crossing 7000 via out-of-network spending trigger 100% in-network? Hmm. That's ambiguous. Standard HDHP: typically separate deductibles/OOPMs for in/out network, but here it's a single balance. The doc 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." Which maximum? For an in-network service, presumably the in-network individual OOPM (7000). The member's balance measured against that...
Hmm, let me just compute and see if these edge cases actually arise. Let's process.
Line 1 — Claim 1 — 2026-01-07 — A — Generic retail pharmacy, in-network. Allowed 74.87.
Family deductible balance 0, room 6400. deductible_applied = min(74.87, 6400) = 74.87.
Member responsibility = 74.87 (all deductible, no coinsurance). Plan paid = 0.00.
A deductible: 74.87. A OOP: 74.87. Family deductible: 74.87. Family OOP: 74.87.
Line 2 — Claim 2 — 2026-01-17 — C — Inpatient, OON. Allowed 10883.95.
OON: threshold individual 6400 measured against C's single deductible balance (0). Room = 6400. deductible_applied = min(10883.95, 6400) = 6400.00.
Remaining allowed after deductible = 10883.95 - 6400 = 4483.95. Coinsurance OON 40% member: 4483.95 * 0.4 = 1793.58. Member resp = 6400 + 1793.58 = 8193.58. Plan paid = 10883.95 - 8193.58 = 2690.37.
Check: 4483.95 * 0.6 = 2690.37. Yes.
C deductible: 6400. C OOP: 8193.58. Family deductible: 74.87 + 6400 = 6474.87. Family OOP: 74.87 + 8193.58 = 8268.45.
Note: C's OON individual OOPM is 14000; C's OOP 8193.58 < 14000, fine. Family OOP 8268.45 < 14000. C's balance 8193.58 > 7000 (in-network individual OOPM) — hmm, but that's from OON claims. Does that matter for future in-network claims? The C child's OOP balance is 8193.58, which exceeds the in-network individual OOPM of 7000. Does that mean C is at 100% for in-network services? Hmm.
This is the tricky ambiguity. Let's keep processing and see. Also family OOP: 8268.45 < 14000.
Actually, let's think: the doc 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." With a single OOP balance and different thresholds by network, the natural reading for an in-network claim: the applicable threshold is the individual in-network OOPM 7000 (and family in-network 14000). If member's balance >= 7000, member at 100% for in-network. C's balance is 8193.58 ≥ 7000. Hmm, but that balance includes OON cost share which is subject to a higher threshold. The rule says "the balances are not capped at the in-network amounts" — this statement is about balances continuing to accumulate (i.e., we don't cap the balance at 7000 or 14000). It doesn't directly say whether crossing 7000 via OON spending triggers in-network 100%.
Hmm, but "measured against the out-of-network individual thresholds only" for OON claims. For in-network claims, what thresholds? Presumably individual in-network (7000) and family in-network (14000). The member's balance is a single balance. So an in-network claim is measured against 7000: if balance >= 7000, no cost share.
Hmm, but that seems odd: C spent 8193.58 out-of-network; the OON OOPM is 14000, so C is not done for OON. But for in-network, C's balance 8193.58 ≥ 7000 means in-network is free? Under standard plan design with separate in/out-network accumulators, no. But here the balance is single. Hmm.
Actually wait. Let me reconsider. Maybe the intended design: single OOP balance; the threshold that applies depends on the network of the service: in-network service → 7000 (individual) / 14000 (family); OON service → 14000 (individual). "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." This strongly implies in-network claims ARE measured against both individual (7000) and family (14000) thresholds.
So in-network claim: no cost share if member balance >= 7000 OR family balance >= 14000.
C's balance is 8193.58 after claim 2. So C's in-network claims would be at 100%? Hmm wait, but that seems to give a weird result where OON spending satisfies the in-network OOPM. Actually, that's a real design in some plans: "single OOPM" where in-network OOPM is lower... Actually no. Let me think about the harness author's intent.
The harness rules say: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
This sentence exists to tell us not to cap the balance at 7000 when processing OON claims. It acknowledges balances can go past in-network individual amount. Then for in-network claims, the measurement is against 7000 presumably. If the author intended that crossing 7000 via OON triggers in-network 100%, then... hmm.
Let me just carefully compute both ways and see which produces "cleaner" results. Actually, let's first process everything with the straightforward interpretation:
- In-network claim cost share: if member OOP balance >= 7000 or family OOP balance >= 14000 → plan pays 100%, member 0. Else, deductible_applied = min(allowed, family deductible room) (aggregate: family threshold 6400); then coinsurance 10% on remainder.
- OON claim: if member OOP balance >= 14000 → 100%. Else deductible_applied = min(allowed, 6400 - member deductible balance); coinsurance 40% on remainder. Note: also need to consider OOPM interplay — if deductible applies fully, member resp = deductible + 40% coinsurance.
Wait, also for in-network claims: after family deductible met, coinsurance 10%. But also member OOP balance vs 7000: once member's balance hits 7000, 100%. And family: once family OOP hits 14000, everyone at 100% for in-network.
Also, subtle: when a member is at 100% due to OOPM, their claims generate no member responsibility, hence no deductible credits either? Hmm — if plan pays 100%, member responsibility = 0, so deductible_applied = 0? The accumulator addendum says "Once the applicable threshold is met, deductible_applied is 0.00". And OOPM reached → plan pays 100% of allowed → member resp = 0. Deductible credits come from member responsibility (deductible applied is part of member resp). If member resp = 0, deductible applied = 0. Yes, consistent with real plans: after OOPM, no deductible accumulation (member pays nothing).
But wait — can a member still owe deductible after family deductible is met but before OOPM? No: deductible_applied = 0 once family threshold met; then coinsurance 10% until OOPM.
OK let me now process.
State after Line 1:
A: ded 74.87, oop 74.87
B: 0, 0
C: 0, 0
D: 0, 0
E: 0, 0
Family: ded 74.87, oop 74.87
Line 2 — C OON inpatient, allowed 10883.95.
C ded balance 0 → OON room = 6400 - 0 = 6400. ded_applied = min(10883.95, 6400) = 6400.
Remainder 4483.95; coins 40% = 1793.58. Member resp = 8193.58. Plan = 2690.37.
C: ded 6400.00, oop 8193.58. Family: ded 6474.87, oop 8268.45.
Line 3 — C OON lab, allowed 967.99.
C ded balance 6400 → OON room = 6400 - 6400 = 0. ded_applied = 0.
Coins 40% of 967.99 = 387.196 → 387.20 (round half up at end; 387.196 → 387.20). Member resp = 387.20. Plan = 967.99 - 387.20 = 580.79.
C: ded 6400.00, oop 8193.58 + 387.20 = 8580.78. Family: ded 6474.87, oop 8268.45 + 387.20 = 8655.65.
Line 4 — A in-network urgent care, allowed 255.34.
Family ded room = 6400 - 6474.87 = -74.87 → negative, i.e., family deductible already met (exceeded by 74.87 because OON credits pushed past; family balance not capped). Family threshold met → ded_applied = 0.
A OOP balance 74.87 < 7000; family OOP 8655.65 < 14000. So coinsurance 10%: 25.534 → 25.53. Member resp = 25.53. Plan = 255.34 - 25.53 = 229.81.
A: ded 74.87 (unchanged; ded_applied 0), oop 74.87 + 25.53 = 100.40. Family: ded 6474.87, oop 8655.65 + 25.53 = 8681.18.
Hmm wait — rounding: 10% of 255.34 = 25.534 → round half up → 25.53. Plan 229.81. Check member+plan = 255.34. Yes.
Line 5 — A in-network ED, allowed 3545.18.
Family ded met → ded_applied 0. A oop 100.40 < 7000; family oop 8681.18 < 14000.
Coins 10% = 354.518 → 354.52. Member resp 354.52. Plan = 3545.18 - 354.52 = 3190.66.
A: oop 100.40 + 354.52 = 454.92. Family oop 8681.18 + 354.52 = 9035.70.
Line 6 — A in-network allergy testing, allowed 911.89.
Ded 0. Coins 10% = 91.189 → 91.19. Member resp 91.19. Plan 820.70.
A oop: 454.92 + 91.19 = 546.11. Family oop: 9035.70 + 91.19 = 9126.89.
Line 7 — B in-network ambulatory surgery, allowed 7845.50.
Ded 0. B oop 0 < 7000; family oop 9126.89 < 14000.
Coins 10% = 784.55. Member resp 784.55. Plan 7060.95.
B: oop 784.55. Family oop: 9126.89 + 784.55 = 9911.44.
Line 8 — D in-network surgery, allowed 6750.63.
Ded 0. D oop 0. Family oop 9911.44 < 14000.
Coins 10% = 675.063 → 675.06. Member resp 675.06. Plan 6750.63 - 675.06 = 6075.57.
D oop: 675.06. Family oop: 9911.44 + 675.06 = 10586.50.
Line 9 — B in-network inpatient, allowed 12250.27.
Ded 0. B oop 784.55 < 7000. Family oop 10586.50 < 14000.
Coins 10% = 1225.027 → 1225.03. Member resp 1225.03. Plan 12250.27 - 1225.03 = 11025.24.
B oop: 784.55 + 1225.03 = 2009.58. Family oop: 10586.50 + 1225.03 = 11811.53.
Line 10 — D in-network inpatient, allowed 12224.51.
Ded 0. D oop 675.06. Family oop 11811.53 < 14000.
Coins 10% = 1222.451 → 1222.45. Member resp 1222.45. Plan 11002.06.
D oop: 675.06 + 1222.45 = 1897.51. Family oop: 11811.53 + 1222.45 = 13033.98.
Line 11 — D OON annual wellness visit, allowed 664.62.
OON preventive: "An out-of-network preventive service is subject to the out-of-network deductible and coinsurance." So not free.
D ded balance: 0 (D only had in-network claims, which credited... wait, in-network claims under aggregate credit the family deductible, and the member's balance? The addendum says credits accumulate to member's balance AND family balance. In-network claims' deductible_applied credits the member's balance too. But all in-network claims after line 2 had ded_applied 0, so D's balance is 0.)
D ded balance 0 → OON room = 6400. ded_applied = min(664.62, 6400) = 664.62.
Coins on remainder 0. Member resp = 664.62. Plan 0.
D: ded 664.62, oop 1897.51 + 664.62 = 2562.13. Family: ded 6474.87 + 664.62 = 7139.49, oop 13033.98 + 664.62 = 13698.60.
Interesting: family ded balance now 7139.49, which exceeds 6400 (because OON credits pushed past). That's fine per "balances are not capped."
Wait, but hold on. Family ded was 6474.87 after claim 2 (6400 from C's OON + 74.87 from A). Actually let me double check: C's OON claim credited 6400 to C's balance and to family balance. Yes, "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
Family ded after line 2: 74.87 + 6400 = 6474.87. Room under family threshold 6400: 6400 - 6474.87 < 0 → met. So all subsequent in-network claims: ded_applied 0. Good.
Line 12 — B OON pharmacy, allowed 30.19.
B ded balance 0 → OON room 6400. ded_applied = 30.19. Member resp 30.19. Plan 0.
B: ded 30.19, oop 2009.58 + 30.19 = 2039.77. Family: ded 7139.49 + 30.19 = 7169.68, oop 13698.60 + 30.19 = 13728.79.
Line 13 — D OON screening colonoscopy (preventive), allowed 716.51.
OON preventive → subject to OON deductible/coinsurance.
D ded balance 664.62 → room = 6400 - 664.62 = 5735.38. ded_applied = min(716.51, 5735.38) = 716.51. Member resp 716.51. Plan 0.
D: ded 664.62 + 716.51 = 1381.13, oop 2562.13 + 716.51 = 3278.64. Family: ded 7169.68 + 716.51 = 7886.19, oop 13728.79 + 716.51 = 14445.30.
Family OOP now 14445.30 > 14000 (family in-network OOPM). Balances not capped. So family OOP threshold met → all members at 100% for in-network services going forward.
Line 14 — VOID of Claim 3 (C OON lab, allowed 967.99).
Unwind claim 3's credits: ded_applied 0, member resp 387.20. Remove from C's oop and family oop.
C: oop 8580.78 - 387.20 = 8193.58. Family oop: 14445.30 - 387.20 = 14058.10.
Family oop still > 14000. Family ded unchanged 7886.19 (claim 3 had ded_applied 0).
Claim 3 components now all 0.
Line 15 — Claim 15 — A OONjson{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 13,921 tokens
Let me work through this carefully.
Plan: Trinity HDHP 3200, plan year 2026.
- Deductible: AGGREGATE structure. Family (in-network) 6400.00. Individual in-network 3200.00 listed but structure is AGGREGATE — "the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
- Out-of-network individual deductible: 6400.00. "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."
- OOPM: Individual in-network 7000.00, Family in-network 14000.00, Individual out-of-network 14000.00.
- Coinsurance after deductible: in-network 10% member / 90% plan; out-of-network 40% member / 60% plan.
- No copays.
- Preventive in-network: paid at 100%, no cost share, moves no accumulator. Out-of-network preventive: subject to OON deductible and coinsurance.
Accumulator rules from addendum:
- deductible_applied = LESSER of allowed amount and room left under the applicable threshold:
- in-network: family remainder alone (aggregate structure).
- out-of-network: out-of-network individual remainder, measured against the member's same single deductible balance.
- Once threshold is met, deductible_applied = 0.00.
- OOP balance = running total of member_responsibility.
- OON claims measured against OON individual thresholds only; family amounts don't limit OON claims. Credits still accumulate to member balance and family balance.
- OOPM: "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." Individual in-network OOPM 7000; family in-network OOPM 14000; individual OON OOPM 14000.
Hmm, need to think about OOPM structure. The family OOPM is 14000 in-network. Is the family OOPM aggregate or embedded? The plan document says "Family (in-network) 14000.00". It doesn't specify embedded/aggregate for OOPM. The glossary mentions embedded vs aggregate deductible. For 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." That refers to the member reaching their individual OOPM. The family OOPM presumably caps total family out-of-pocket; when family reaches 14000, all members pay nothing.
But the accumulator instructions only define deductible_applied via thresholds. For OOPM, we need to apply: member cost share is capped when member's OOP balance reaches individual OOPM (7000 in-network; 14000 OON?), or family reaches 14000 (in-network).
Wait — individual OON OOPM is 14000. So for OON services, member's OOP balance is measured against 14000? Hmm. The instruction: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim."
So for an OON claim, deductible threshold = individual OON deductible 6400 (against member's single balance); OOPM threshold = individual OON OOPM 14000 (against member's OOP balance). For in-network claims, deductible threshold = family aggregate 6400 (family balance); OOPM threshold = ... individual in-network 7000 (member balance) and family in-network 14000 (family balance)? Presumably both: member pays min based on remaining room under both. Actually for OOPM, typical: member pays until member OOP hits individual OOPM or family OOP hits family OOPM.
Let me just process the ledger.
Initial: all zero.
Line 1 — Claim 1 — A — in-network, allowed 74.87.
In-network deductible threshold: family remainder = 6400.00. deductible_applied = min(74.87, 6400) = 74.87. Since deductible not met, member pays full allowed: member_resp = 74.87, plan_paid = 0.00, coinsurance = 0.00.
Family deductible balance: 74.87. A deductible: 74.87. A OOP: 74.87. Family OOP: 74.87.
Line 2 — Claim 2 — C — OON, allowed 10883.95.
OON deductible threshold: individual OON deductible 6400, measured against C's single deductible balance (0.00). C's remainder = 6400.00. deductible_applied = min(10883.95, 6400) = 6400.00. Remaining allowed after deductible: 10883.95 - 6400.00 = 4483.95. OON coinsurance 40% member: 4483.95 * 0.40 = 1793.58. Check OOPM: individual OON OOPM 14000; C's OOP balance before: 0. Room = 14000. Member responsibility would be 6400 + 1793.58 = 8193.58, under 14000. Family OOPM 14000 is an in-network amount and doesn't limit OON claims. So member_resp = 8193.58, plan_paid = 60% of 4483.95 = 2690.37. Check: 8193.58 + 2690.37 = 10883.95. ✓.
Coinsurance amount for claim 2 = 1793.58. Deductible applied 6400.00.
C deductible balance: 6400.00. C OOP: 8193.58. Family deductible: 74.87 + 6400 = 6474.87. Family OOP: 74.87 + 8193.58 = 8268.45.
Note: family deductible now 6474.87 > 6400. The family in-network deductible is met. But wait — the credits: C's OON claim credits accumulated to family balance. The family in-network deductible threshold is 6400; family balance is 6474.87, which exceeds it. So for subsequent in-network claims, family remainder = max(0, 6400 - 6474.87) = 0. The balance is not capped at 6400, but the threshold is met, so no more deductible applies for in-network.
Hmm, but wait: does an OON claim's deductible credit count toward the family in-network deductible? The addendum says: "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." Yes — the family deductible balance includes OON credits. And the single member deductible balance is shared. So family deductible balance 6474.87 ≥ 6400 → in-network deductible met for everyone (aggregate structure). Interesting.
Line 3 — Claim 3 — C — OON, allowed 967.99.
C's OON deductible remainder: threshold 6400, C balance 6400.00 → remainder 0. deductible_applied = 0. Coinsurance 40%: 967.99 * 0.40 = 387.196 → 387.20 (round half up at end). Check OOPM: C OOP balance 8193.58; individual OON OOPM 14000; room 5806.42. Member resp 387.20 fine. Family OOP 14000 is in-network, doesn't limit OON. So member_resp = 387.20, plan_paid = 967.99 - 387.20 = 580.79 (60% = 580.794 → 580.79; member 387.196→387.20; sum 967.99 ✓ if we use 387.20 + 580.79 = 967.99 ✓).
C OOP: 8193.58 + 387.20 = 8580.78. Family OOP: 8268.45 + 387.20 = 8655.65. C deductible stays 6400.00. Family deductible 6474.87 (deductible_applied 0).
Line 4 — Claim 4 — A — in-network, allowed 255.34.
In-network deductible: family remainder = 6400 - 6474.87 → 0 (met). deductible_applied = 0. Coinsurance 10%: 25.534 → 25.53. Check OOPM: A OOP 74.87; individual in-network OOPM 7000; family in-network OOPM 14000; family OOP balance 8655.65 < 14000. So member pays 25.53, plan 229.81 (90% of 255.34 = 229.806 → 229.81; 25.53+229.81 = 255.34 ✓).
Hmm wait, but family OOPM — is the family OOP balance relevant for in-network claims? Family OOP balance currently 8655.65 which includes OON charges. The family OOPM is 14000 in-network. Does the family OOP balance accumulate OON credits too? Presumably yes ("the balances are not capped at the in-network amounts"). The balance accumulates all member_responsibility. The threshold for in-network claims is family 14000. So family balance 8655.65 < 14000, fine.
A OOP: 74.87 + 25.53 = 100.40. Family OOP: 8655.65 + 25.53 = 8681.18.
Line 5 — Claim 5 — A — in-network ED, allowed 3545.18.
Deductible met (family). Coinsurance 10%: 354.518 → 354.52. OOPM check: A OOP 100.40, room to 7000 fine; family 8681.18 room to 14000 fine. member_resp 354.52, plan 3190.66 (90% = 3190.662 → 3190.66; sum ✓ 354.52+3190.66 = 3545.18 ✓).
A OOP: 100.40 + 354.52 = 454.92. Family OOP: 8681.18 + 354.52 = 9035.70.
Line 6 — Claim 6 — A — in-network allergy testing, allowed 911.89. (Later VOIDED at Line 16.)
Coinsurance 10%: 91.189 → 91.19. member_resp 91.19, plan 820.70 (90% = 820.701 → 820.70; sum 91.19+820.70 = 911.89 ✓).
A OOP: 454.92 + 91.19 = 546.11. Family OOP: 9035.70 + 91.19 = 9126.89.
Line 7 — Claim 7 — B — in-network ambulatory surgery, allowed 7845.50.
Deductible met. Coinsurance 10%: 784.55. member_resp 784.55, plan 7060.95.
B OOP: 784.55. Family OOP: 9126.89 + 784.55 = 9911.44.
Line 8 — Claim 8 — D — in-network ambulatory surgery, allowed 6750.63.
Coinsurance 10%: 675.063 → 675.06. member_resp 675.06, plan 6075.57 (sum 675.06+6075.57 = 6750.63 ✓).
D OOP: 675.06. Family OOP: 9911.44 + 675.06 = 10586.50.
Line 9 — Claim 9 — B — in-network inpatient, allowed 12250.27.
Coinsurance 10%: 1225.027 → 1225.03. member_resp 1225.03, plan 11025.24 (90% = 11025.243 → 11025.24; sum 1225.03+11025.24 = 12250.27 ✓).
B OOP: 784.55 + 1225.03 = 2009.58. Family OOP: 10586.50 + 1225.03 = 11811.53.
Line 10 — Claim 10 — D — in-network inpatient, allowed 12224.51.
Coinsurance 10%: 1222.451 → 1222.45. member_resp 1222.45, plan 11002.06 (90% = 11002.059 → 11002.06; sum ✓).
D OOP: 675.06 + 1222.45 = 1897.51. Family OOP: 11811.53 + 1222.45 = 13033.98.
Note family OOP now 13033.98, room to 14000 = 966.02.
Line 11 — Claim 11 — D — OON annual wellness visit (preventive), allowed 664.62.
OON preventive is subject to OON deductible and coinsurance (per family rules: "An out-of-network preventive service is subject to the out-of-network deductible and coinsurance"). D's single deductible balance: 0.00. OON individual deductible threshold 6400 → remainder 6400. deductible_applied = min(664.62, 6400) = 664.62. Member pays full 664.62 (no coinsurance since deductible covers all; coinsurance amount = 0). Check OOPM: D OOP 1897.51; OON individual OOPM 14000; fine. member_resp 664.62, plan 0.00.
D deductible balance: 664.62. D OOP: 1897.51 + 664.62 = 2562.13. Family deductible: 6474.87 + 664.62 = 7139.49. Family OOP: 13033.98 + 664.62 = 13698.60.
Family OOP room to 14000: 301.40.
Line 12 — Claim 12 — B — OON generic retail pharmacy, allowed 30.19.
OON. B's deductible balance: 0.00 (B has had only in-network claims, which under aggregate... wait, under aggregate structure, in-network claims credit the family deductible, not the individual. But the member's "single deductible balance" — hmm. Under aggregate structure, "There is no individual deductible under this structure." The accumulator instructions say for in-network, deductible_applied measured against family remainder alone. But each member also has a deductible accumulator listed. What does the member's deductible balance mean under aggregate? The initial state lists each member's deductible. The addendum says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." So each member has a balance that includes both in-network and OON credits. Under aggregate, the in-network threshold is the family remainder; but the member's own balance still accumulates credits (their claims' deductible_applied amounts).
Hmm, this matters for OON claims: "out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance." So for an OON claim, we measure the member's balance against 6400. For B: balance 0.00 (Claim 7 and 9 were in-network; under aggregate, deductible_applied for those was 0 because family deductible was met; so B's balance stays 0.00). Wait — but did B's in-network claims credit anything to B's own deductible balance? deductible_applied was 0.00 for claims 7 and 9 (family deductible met). So B's balance is 0.00.
Claim 12: deductible_applied = min(30.19, 6400 - 0) = 30.19. Member pays 30.19, plan 0.00. Coinsurance 0.
B deductible balance: 30.19. B OOP: 2009.58 + 30.19 = 2039.77. Family deductible: 7139.49 + 30.19 = 7169.68. Family OOP: 13698.60 + 30.19 = 13728.79.
Family OOP room: 271.21.
Line 13 — Claim 13 — D — OON screening colonoscopy (preventive, no polyp), allowed 716.51.
OON preventive → subject to OON deductible and coinsurance. D's balance: 664.62. Remainder to 6400: 5735.38. deductible_applied = min(716.51, 5735.38) = 716.51. Member pays 716.51, plan 0.00. Coinsurance 0.
D deductible: 664.62 + 716.51 = 1381.13. D OOP: 2562.13 + 716.51 = 3278.64. Family deductible: 7169.68 + 716.51 = 7886.19. Family OOP: 13728.79 + 716.51 = 14445.30.
Now family OOP balance 14445.30 > 14000 (family in-network OOPM). The balance is not capped ("balances are not capped at the in-network amounts"), but the threshold is met: for in-network claims, family OOPM is reached → plan pays 100%? Wait, the OOPM: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount." The family OOPM of 14000 — when the family balance reaches it, all members' in-network cost share ends. Hmm, but is the family OOPM aggregate? The plan document lists family OOPM 14000 in-network. Since the deductible is aggregate, the OOPM might also be aggregate (family total). The document doesn't explicitly say embedded or aggregate for OOPM. Given the deductible is explicitly AGGREGATE, and the family OOPM is 14000 = 2 × 7000 individual, typical aggregate family OOPM.
But here's the subtlety: family OOP balance includes OON credits (14445.30). Does reaching 14000 via OON charges trigger the family in-network OOPM? The addendum says: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." It says family amounts don't limit OON claims. But the family balance has been inflated by OON credits. For an in-network claim, the threshold is family 14000, and the family balance (which includes OON credits) is 14445.30 ≥ 14000. So in-network family OOPM is met.
Hmm, is that the intended reading? "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." And "the balances are not capped at the in-network amounts." So yes, family OOP balance = sum of all member_responsibility across all claims = 14445.30. For in-network claims, the applicable OOPM thresholds: individual 7000 (member balance) and family 14000 (family balance). Both are checked. Family balance ≥ 14000 → no more member cost share for in-network claims.
This will matter a lot for subsequent in-network claims (Claims 19, 21, 22, 24, 25).
Wait, but let me double check the OOPM application. Actually, let me re-read: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services." Note: "covered in-network services" — interesting, the glossary says plan pays 100% for covered in-network services once reached. 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." Hmm, plan document doesn't restrict to in-network. But the individual OON OOPM is 14000, so OON claims have their own threshold.
OK so mechanics: for each claim, member cost share = deductible_applied + coinsurance, but capped by OOPM room:
- In-network claims: room = min(7000 - member OOP balance, 14000 - family OOP balance)? Or is the cap applied such that member pays min(computed cost share, remaining room under applicable OOPM)? I think yes: the member's cost share cannot push their OOP balance past their individual OOPM, nor the family past the family OOPM. Once either is reached, plan pays 100%.
Hmm, but actually there's a subtlety: under an aggregate family OOPM, when family reaches 14000, everyone is done. Under embedded, each member done at 7000 individually. Here, individual in-network OOPM 7000 and family 14000 — that's consistent with either embedded or aggregate (aggregate family OOPM typically = 2× individual for non-embedded). Since the deductible is explicitly aggregate, I'll treat the OOPM as aggregate family too: family balance reaching 14000 ends member cost share for all members (in-network). Also individual members end at their own 7000.
Let me continue.
Line 14 — VOID of Claim 3 — 2026-06-06.
Claim 3 credits: deductible_applied 0.00, member_resp 387.20. Unwind: C OOP 8580.78 - 387.20 = 8193.58. Family OOP: was 8655.65 after claim 3... let me track family OOP carefully. Actually the void happens at line 14, after claims 4–13 have posted. The unwinding removes Claim 3's credits from accumulators as they stand now. Claim 3's credits: member_resp 387.20 (OOP) and deductible_applied 0.00. So:
Family OOP before void (after line 13): 14445.30. Remove 387.20 → 14058.10.
C OOP before void: 8580.78. Remove 387.20 → 8193.58.
C deductible: 6400.00 (claim 3 applied 0) unchanged.
Family deductible: unchanged 7886.19.
Claim 3 is now off the books: components 0.00 (not asked, but note).
Line 15 — Claim 15 — A — OON outpatient endoscopy, allowed 2331.25.
OON: A's single deductible balance: A's deductible accumulator = 74.87 (from Claim 1; claims 4,5,6 had deductible_applied 0 since family met). So A balance 74.87. OON remainder: 6400 - 74.87 = 6325.13. deductible_applied = min(2331.25, 6325.13) = 2331.25. Member pays full 2331.25. Coinsurance 0. OOPM check: A OOP balance currently: let's track A's OOP.
A OOP after line 13: 546.11 (74.87 + 25.53 + 354.52 + 91.19). Wait, but Claim 6 (allergy testing) gets voided at line 16, not yet. So A OOP = 546.11 at this point. OON individual OOPM 14000; room plenty. member_resp 2331.25, plan 0.00.
A deductible balance: 74.87 + 2331.25 = 2406.12. A OOP: 546.11 + 2331.25 = 2877.36. Family deductible: 7886.19 + 2331.25 = 10217.44. Family OOP: 14058.10 + 2331.25 = 16389.35.
Line 16 — VOID of Claim 6 — 2026-06-22.
Claim 6 credits: member_resp 91.19, deductible_applied 0.00, plan paid 820.70. Unwind:
A OOP: 2877.36 - 91.19 = 2786.17.
Family OOP: 16389.35 - 91.19 = 16298.16.
A deductible: unchanged 2406.12. Family deductible unchanged 10217.44.
Line 17 — Claim 17 — E — OON physical therapy, allowed 1373.69.
E balance: 0.00. OON remainder 6400. deductible_applied = 1373.69. Member pays 1373.69, plan 0. E OOP: 1373.69. E deductible: 1373.69. Family deductible: 10217.44 + 1373.69 = 11591.13. Family OOP: 16298.16 + 1373.69 = 17671.85.
Line 18 — Claim 18 — C — OON diagnostic lab, allowed 593.21.
C balance: 6400.00 (Claim 2 applied 6400; claim 3 voided). OON remainder: 0. deductible_applied = 0. Coinsurance 40%: 593.21 × 0.40 = 237.284 → 237.28. OOPM: C OON individual OOPM 14000; C OOP balance 8193.58; room 5806.42. Fine. member_resp 237.28, plan 355.93 (60% = 355.926 → 355.93; sum 237.28 + 355.93 = 593.21 ✓).
C OOP: 8193.58 + 237.28 = 8430.86. Family OOP: 17671.85 + 237.28 = 17909.13.
Line 19 — Claim 19 — B — in-network urgent care, allowed 220.46.
In-network. Deductible: family balance 11591.13 ≥ 6400 → met. deductible_applied 0. Coinsurance 10%: 22.046 → 22.05 (round half up: 22.046 → 22.05). OOPM check: family OOP balance 17909.13 ≥ 14000 → family in-network OOPM met → plan pays 100%? Hmm.
This is the crux. Family OOP balance (sum of all member responsibilities) = 17909.13, which exceeds the family in-network OOPM of 14000. The addendum: "the balances are not capped at the in-network amounts" — meaning the balance keeps accumulating beyond 14000, but the threshold check for in-network claims uses 14000. Family balance ≥ 14000 → family OOPM met → no member cost share for in-network services.
But wait — should OON credits count toward the family in-network OOPM threshold? The addendum says: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
So OON credits DO accumulate to the family balance. And the family balance is what's measured against the family threshold for in-network claims. The addendum explicitly says the credits accumulate to "the family balance" — singular, the sajson{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 20,017 tokens
Let me work through this carefully.
Plan: Trinity HDHP 3200, plan year 2026.
- Aggregate deductible: family in-network deductible 6400.00. No individual deductible. The plan pays no coinsurance for any member until total family credits reach the family deductible amount (6400.00 in-network).
- Out-of-network individual deductible 6400.00. Measured against the member's same single deductible balance. So the out-of-network threshold for a member is 6400.00 (individual OON deductible).
- OOPM: individual in-network 7000.00, family in-network 14000.00, individual out-of-network 14000.00.
- Coinsurance after deductible: in-network 10% member / 90% plan; out-of-network 40% member / 60% plan.
- No copays.
- Preventive in-network: paid 100%, no cost share, moves no accumulator. Out-of-network preventive: subject to OON deductible and coinsurance.
- Deductible_applied for in-network claims (aggregate): the family remainder alone. Wait, let me re-read the ACCUMULATORS addendum:
"in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);"
Under aggregate, the threshold is the family deductible 6400.00. So deductible_applied for an in-network claim is the lesser of its allowed amount and the family remainder (family deductible 6400.00 minus family deductible balance).
Hmm, but wait — there's a subtlety. Under aggregate structure, "no member reaches coinsurance until the family amount is met." So the deductible threshold that applies to an in-network claim is the family deductible (6400.00), measured against the family deductible balance.
For out-of-network claims: "the out-of-network individual remainder, measured against the member's same single deductible balance." The OON individual deductible is 6400.00. So deductible_applied for an OON claim is the lesser of its allowed amount and (6400.00 − member's deductible balance). "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim."
But wait — once the family (in-network) deductible is met, does an OON claim stop crediting the deductible? Hmm. Let's think. The single member deductible balance accumulates both in-network and OON credits. The in-network threshold (family aggregate 6400.00) applies to in-network claims; the OON threshold (individual 6400.00) applies to OON claims, measured against the member's balance.
So a member's OON claim credits deductible until the member's own balance reaches 6400.00. Even if the family in-network deductible is fully met (family balance 6400), an OON claim from a member whose own balance is below 6400 continues to credit deductible at 40% coinsurance... wait no. Let me think about the cost share.
For an OON claim: member pays... the deductible portion first (deductible_applied), then coinsurance on the remainder at 40%? Under aggregate, does the OON claim's coinsurance kick in only after family deductible? No — OON claims are measured against the OON individual threshold only. So for an OON claim from member M: if M's deductible balance < 6400, the claim credits deductible (lesser of allowed and remaining room), and member responsibility = deductible_applied + coinsurance on the excess? Hmm, actually is the excess subject to coinsurance at all before the threshold is met?
Standard HDHP: before the deductible is met, the member pays the full allowed amount (which credits the deductible). Coinsurance applies after the deductible. For a single claim that crosses the threshold, the part below the threshold is deductible, the part above is coinsured.
So for an OON claim: deductible_applied = min(allowed, OON room = 6400 − member balance). Member responsibility = deductible_applied + coinsurance_rate × (allowed − deductible_applied). Plan pays allowed − member responsibility.
But hold on — under an aggregate family structure, in-network claims only start coinsurance after family deductible is met. For OON claims, the "threshold that applies to it" is the OON individual deductible. The coinsurance question: is OON coinsurance gated on the member's own OON deductible being met, or also on the family? The plan says "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." So OON coinsurance begins once the member's single deductible balance reaches 6400 (the OON individual threshold).
Hmm, but here's another subtlety: the member's "same single deductible balance" accumulates both in-network and OON credits. So in-network credits count toward the member's OON threshold too. E.g., member has 3000 of in-network deductible credits; an OON claim has 3400 of room left under the OON threshold.
But careful: does an in-network credit count toward the OON threshold? "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." Yes — the single balance is measured against the OON threshold for OON services. So in-network credits help satisfy the OON deductible.
Wait, but there's asymmetry: in-network claims measure the family remainder (aggregate). So in-network credits only accrue while family balance < 6400. OON credits accrue while member balance < 6400. The member's balance could exceed... no, OON credits stop at member balance 6400.
Also OOPM: individual in-network 7000, family in-network 14000, individual OON 14000. How do OOPM thresholds gate cost share? The OOPM is a ceiling: once reached, plan pays 100%. Which threshold applies to which claim? Presumably in-network claims are measured against the in-network OOPM — but is it individual or family? Typically family OOPM matters for aggregate structures... 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."
Hmm. The deductible section explicitly describes aggregate for deductible but the OOPM section lists individual 7000, family 14000, individual OON 14000. The structure field says "AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount." That's about the deductible. For OOPM, is it embedded or aggregate? The ACCUMULATORS addendum says "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." This suggests for in-network claims, both individual and family thresholds could apply? "the family amounts, which are in-network amounts" — so family in-network OOPM 14000 applies to in-network claims.
Hmm, this is ambiguous. Let me consider: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
So OOP balances aren't capped; once a member's OOP balance ≥ 7000 (in-network individual OOPM), the plan pays 100% for... in-network services? And if OOP balance ≥ 14000, 100% for OON too? And family OOPM 14000 for in-network: once family OOP balance reaches 14000, plan pays 100% for all members in-network?
This is getting complicated. Let me just simulate and see whether these thresholds actually bind in this ledger.
Let me process line by line.
Initial accumulators: all zero.
Line 1 — Claim 1 — A — in-network, generic retail pharmacy, allowed 74.87.
Aggregate deductible: family remainder = 6400 − 0 = 6400. deductible_applied = min(74.87, 6400) = 74.87. Member pays full allowed (no coinsurance yet since family deductible not met). Member responsibility = 74.87, plan paid = 0.00. Coinsurance = 0.00, copay = 0.00.
Update: A deductible 74.87, A OOP 74.87. Family deductible 74.87, family OOP 74.87.
Line 2 — Claim 2 — C — OON inpatient, allowed 10883.95.
OON: threshold = member C's single deductible balance vs OON individual 6400. C balance 0. Room = 6400. deductible_applied = min(10883.95, 6400) = 6400.00. Excess = 10883.95 − 6400 = 4483.95, coinsured at 40% member: 1793.58. Member responsibility = 6400 + 1793.58 = 8193.58. Plan paid = 10883.95 − 8193.58 = 2690.37.
Wait — is the excess coinsured at 40% even though family deductible not met? For OON claims, "measured against the out-of-network individual thresholds only" — so yes, OON coinsurance begins once member's balance reaches the OON individual threshold (6400). Within this claim, the first 6400 is deductible, the excess is coinsurance at 40%.
Hmm, but wait — is that right? Under an aggregate deductible, no member gets coinsurance until family deductible met. But the OON rules override: OON claims are measured against OON individual thresholds only, and the family amounts "do not limit an out-of-network claim." The OON individual deductible is 6400. So C's claim: deductible 6400, then coinsurance on excess.
Actually, let me reconsider. Another reading: under an aggregate structure, the OON claim credits deductible up to the OON threshold, and the excess is subject to OON coinsurance only if the member's OON deductible is met. Since within a single claim the member crosses the threshold, the portion above is coinsured. That's the standard treatment and consistent with "deductible_applied is the LESSER of its allowed amount and the room left."
Member responsibility = 6400.00 + 0.40 × 4483.95 = 6400.00 + 1793.58 = 8193.58. Plan = 2690.37.
Check: 6400 + 1793.58 + 2690.37 = 10883.95. ✓
Update: C deductible 6400.00 (member's single balance now 6400). C OOP 8193.58. Family deductible 6400 + 74.87 = 6474.87. Family OOP 74.87 + 8193.58 = 8268.45.
Note family deductible balance now 6474.87 ≥ 6400. Family (in-network aggregate) deductible is MET. So subsequent in-network claims: deductible_applied = 0 (family remainder 0), coinsurance 10% member in-network.
Wait — family deductible is 6400 and family balance is 6474.87 (74.87 from A + 6400 from C's OON credits). The OON credits accumulate to family balance too ("The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."). So the family in-network aggregate threshold is measured against the family balance, which includes OON credits. Family balance 6474.87 > 6400, so in-network deductible is met for everyone. Hmm, that's a big consequence. Let me double check: "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." Yes.
So after Line 2, family deductible balance = 6474.87, which exceeds the 6400 aggregate threshold. All subsequent in-network claims have deductible_applied 0.00 and 10% coinsurance (subject to OOPM).
Line 3 — Claim 3 — C — OON diagnostic lab, allowed 967.99.
C's deductible balance = 6400 = OON threshold. Room = 0. deductible_applied = 0. Coinsurance 40%: member = 387.196 → 387.20. Plan = 580.79. Check: 387.20 + 580.79 = 967.99. ✓ (967.99 × 0.4 = 387.196; round half up to 387.20. Plan = 967.99 − 387.20 = 580.79.)
Update: C deductible stays 6400. C OOP 8193.58 + 387.20 = 8580.78. Family deductible 6474.87 (no change). Family OOP 8268.45 + 387.20 = 8655.65.
Line 4 — Claim 4 — A — in-network urgent care, allowed 255.34.
Family deductible met → deductible_applied 0. Coinsurance 10%: member = 25.534 → 25.53. Plan = 229.81. Check 25.53+229.81 = 255.34 ✓.
Update: A OOP 74.87 + 25.53 = 100.40. Family OOP 8655.65 + 25.53 = 8681.18. A deductible stays 74.87? Family deductible stays 6474.87.
Hmm wait — should in-network claims after family deductible met still credit the member's individual deductible balance? No: deductible_applied = 0, so no credits.
Line 5 — Claim 5 — A — in-network ED, allowed 3545.18.
Deductible 0. Coinsurance 10%: 354.518 → 354.52. Plan = 3190.66. Check 354.52+3190.66=3545.18 ✓.
Update: A OOP 100.40 + 354.52 = 454.92. Family OOP 8681.18 + 354.52 = 9035.70.
Line 6 — Claim 6 — A — in-network allergy testing, allowed 911.89.
Coinsurance 10%: 91.189 → 91.19. Plan = 820.70. ✓ (91.19 + 820.70 = 911.89).
Update: A OOP 454.92 + 91.19 = 546.11. Family OOP 9035.70 + 91.19 = 9126.89.
Line 7 — Claim 7 — B — in-network ambulatory surgery, allowed 7845.50.
Family deductible met. Coinsurance 10%: 784.55. Plan = 7060.95. ✓.
But check OOPM: A... no wait, B's OOP balance is 0 before this. Family OOP 9126.89. Individual in-network OOPM 7000 — B at 0, after this claim B OOP = 784.55. Family OOPM 14000: family OOP after = 9126.89 + 784.55 = 9911.44 < 14000. Fine.
Also, does the family OOPM cap apply mid-claim? Not reached. B OOP = 784.55. Family OOP = 9911.44.
Line 8 — Claim 8 — D — in-network ambulatory surgery, allowed 6750.63.
Coinsurance 10%: 675.063 → 675.06. Plan = 6075.57. ✓ (675.06+6075.57=6750.63).
Update: D OOP 675.06. Family OOP 9911.44 + 675.06 = 10586.50.
Line 9 — Claim 9 — B — in-network inpatient, allowed 12250.27.
Coinsurance 10%: 1225.027 → 1225.03. Plan = 11025.24. ✓.
B OOP: 784.55 + 1225.03 = 2009.58. Family OOP: 10586.50 + 1225.03 = 11811.53.
Check OOPM: B individual 7000 not reached. Family 14000 not reached (11811.53).
Line 10 — Claim 10 — D — in-network inpatient, allowed 12224.51.
Coinsurance 10%: 1222.451 → 1222.45. Plan = 11002.06. ✓ (1222.45 + 11002.06 = 12224.51).
D OOP: 675.06 + 1222.45 = 1897.51. Family OOP: 11811.53 + 1222.45 = 13033.98.
Family OOP 13033.98 < 14000. Individual D 1897.51 < 7000.
Line 11 — Claim 11 — D — OON annual wellness visit (preventive), allowed 664.62.
Out-of-network preventive service: subject to OON deductible and coinsurance (per family rules: "An out-of-network preventive service is subject to the out-of-network deductible and coinsurance."). D's deductible balance = 0 (D had no deductible credits yet; only OOP from coinsurance). OON room = 6400 − 0 = 6400. deductible_applied = min(664.62, 6400) = 664.62. Member responsibility = 664.62 (all deductible; the excess is 0 so no coinsurance). Plan = 0.00.
Update: D deductible balance 664.62. D OOP 1897.51 + 664.62 = 2562.13. Family deductible 6474.87 + 664.62 = 7139.49. Family OOP 13033.98 + 664.62 = 13698.60.
Hmm wait — does the OON deductible credit accumulate to the family deductible balance? "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." Yes. Family deductible balance now 7139.49. That's above 6400 anyway; in-network remains met.
Also, family OOP is now 13698.60, approaching 14000.
Line 12 — Claim 12 — B — OON generic retail pharmacy, allowed 30.19.
B deductible balance = 0. OON room = 6400. deductible_applied = 30.19. Member = 30.19. Plan = 0.
Update: B deductible 30.19. B OOP 2009.58 + 30.19 = 2039.77. Family deductible 7139.49 + 30.19 = 7169.68. Family OOP 13698.60 + 30.19 = 13728.79.
Line 13 — Claim 13 — D — OON screening colonoscopy (preventive, no polyp), allowed 716.51.
OON preventive → subject to OON deductible/coinsurance. D deductible balance 664.62. Room = 6400 − 664.62 = 5735.38. deductible_applied = 716.51. Member = 716.51. Plan = 0.
Update: D deductible 664.62 + 716.51 = 1381.13. D OOP 2562.13 + 716.51 = 3278.64. Family deductible 7169.68 + 716.51 = 7886.19. Family OOP 13728.79 + 716.51 = 14445.30.
Family OOP now 14445.30 ≥ 14000 (family in-network OOPM). Hmm — the family OOPM is 14000 in-network. Does reaching it mean the plan pays 100% for all members' in-network services going forward? "Once a member reaches the out-of-pocket maximum the plan pays 100%..." — that speaks of a member reaching. The family OOPM in an aggregate/embedded structure: typically family OOPM means when family total reaches it, all members are at 100%. The plan document lists "Family (in-network) 14000.00" under OOPM. The glossary: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services."
Hmm. The family OOPM is a ceiling on member cost share — when family OOP balance reaches 14000, does everyone's in-network cost share stop? I think for the family OOPM in aggregate structures, yes: once the family reaches the family OOPM, the plan pays 100% for all family members (in-network). Let me hold that thought and see if it matters.
Note: this claim crossed the family OOPM mid-claim. Family OOP before: 13728.79. Room to 14000: 271.21. The claim's member responsibility 716.51 — should it be capped at 271.21? Hmm. Typically OOPM is applied at adjudication: the member pays until the OOPM is reached, then 100%. If a single claim crosses the threshold, the member responsibility is capped at the remaining room. The addendum says balances are "not capped at the in-network amounts" — meaning balances can exceed thresholds due to OON claims (since OON claims measure against higher OON thresholds, they keep charging cost share even after in-network thresholds are passed). Hmm, wait — that sentence says out-of-network claims can carry a member's balance past the in-network individual amount and family balances past the family amounts. So OON claims do NOT stop charging when family OOPM (14000, in-network) is passed? Because OON claims are measured against OON individual thresholds (14000) only, and family amounts "do not limit an out-of-network claim."
So: does the family in-network OOPM (14000) apply to in-network claims? And the individual in-network OOPM (7000) applies to in-network claims? And the individual OON OOPM (14000) applies to OON claims?
I think the intended mechanics:
- In-network claim: member pays cost share until either the member's OOP balance reaches 7000 (individual in-network OOPM) or the family OOP balance reaches 14000 (family in-network OOPM). Then 100% plan paid.
- OON claim: member pays until member's OOP balance reaches 14000 (individual OON OOPM). Family amounts don't limit OON claims.
The sentence "out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts" confirms: an OON claim keeps charging even after member OOP > 7000 and family OOP > 14000; OON stops only at member OOP 14000.
So the family OOPM 14000 gates in-network claims. Once family OOP balance ≥ 14000, in-network claims pay 100% plan.
Now, at Line 13, family OOP went from 13728.79 to 14445.30. The claim crossed the family OOPM. Should member responsibility have been capped at 271.21 (the room to 14000)? Hmm. This matters for D's OOP and family OOP totals, and downstream for whether family OOPM gates later in-network claims.
The standard way these harnesses usually work: the OOPM caps member cost share — a claim that would push the balance past the OOPM gets its member responsibility truncated so the balance lands exactly at the OOPM. The glossary says "the ceiling on member cost share for the plan year." A ceiling suggests the balance shouldn't exceed it via in-network claims. But the addendum says balances are "not capped at the in-network amounts" — specifically in the context of OON claims carrying balances past in-network amounts.
Hmm, tricky. Let me think about whether the harness intends mid-claim capping. The deductible rules explicitly describe mid-claim crossing (deductible_applied = lesser of allowed and room left; then coinsurance on the excess). For the 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." That's phrased as a state change, not a per-claim truncation.
Two possible treatments for Line 13:
(a) Fulljson{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}100Hunyuan 4 · Tencent422.8s · 25,911 out | 531.4s · 29,144 out | 403.1s · 23,560 out
Reasoning · 25,491 tokens
We need answer only JSON code block. Need compute ledger. Let's understand plan.
Plan: Trinity HDHP 3200, plan year 2026. Deductible: Individual in-network 3200.00, Family in-network 6400.00. Structure AGGREGATE — plan pays no coinsurance for any member until total family credits reach family deductible amount. There is no individual deductible under this structure. Out-of-network (individual) ... 6400.00. 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's a single deductible balance per member? Let's parse.
"Deductible
Individual (in-network) ................ 3200.00
Family (in-network) .................... 6400.00
Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure.
Out-of-network (individual) ............ 6400.00
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 "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." Means each member has one deductible balance? Or family single balance? Let's read carefully.
"ACCUMULATORS (addendum to the plan document)
A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
in-network ......... the smaller of the member's individual remainder and
the family remainder (embedded), or the family
remainder alone (aggregate);
out-of-network ..... the out-of-network individual remainder, measured
against the member's same single deductible balance.
Once the applicable threshold is met, deductible_applied is 0.00, including
for a copay that would otherwise credit the deductible.
A balance is the running total of deductible_applied (for a deductible) or
of member_responsibility (for an out-of-pocket balance). Because the
out-of-network thresholds are higher, out-of-network claims can carry a
member's balance past the in-network individual amount, and the family
balances past the family amounts; the balances are not capped at the
in-network amounts.
Out-of-network claims are measured against the out-of-network individual
thresholds only; the family amounts, which are in-network amounts, do not
limit an out-of-network claim. The credits an out-of-network claim generates
still accumulate to the member's balance and to the family balance."
Let's parse: Aggregate structure: in-network claims: deductible_applied is lesser of allowed amount and the room left under the deductible threshold that applies: for in-network under aggregate, it's the family remainder alone (since no individual deductible under aggregate). Wait text says: "in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);" So for aggregate, in-network deductible_applied = lesser(allowed, family remainder). The family remainder = family deductible (6400.00) - family deductible balance (total credits applied to family). Once family balance reaches 6400, room left = 0, so in-network deductible_applied = 0. Then coinsurance applies (after deductible is satisfied). Also there is no individual deductible under this structure, meaning individual in-network 3200? Wait it says "Individual (in-network) ................ 3200.00 Family (in-network) .................... 6400.00 Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." So the individual in-network 3200 is listed but "There is no individual deductible under this structure"? Hmm contradictory. It lists Individual (in-network) 3200.00, Family (in-network) 6400.00. Structure AGGREGATE — plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure. Actually likely means there is no *embedded* individual deductible; the 3200 individual amount is not used as a separate trigger? Wait "There is no individual deductible under this structure." But it just gave Individual (in-network) 3200.00. Maybe the 3200 is the individual out-of-pocket? Let's re-read: Deductible section: Individual (in-network) 3200.00, Family (in-network) 6400.00. Structure AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure. Out-of-network (individual) 6400.00. Hmm.
Actually typical HDHP: embedded deductible: each individual has deductible 3200, family 6400; family aggregate: entire family deductible 6400 must be met before any individual gets coinsurance; there is no *individual* deductible that can be met separately, but the individual amount might be used for out-of-pocket? Wait Out-of-pocket maximum section: Individual (in-network) 7000.00, Family (in-network) 14000.00, Individual (out-of-network) 14000.00. So deductible: Individual (in-network) 3200.00 maybe is the individual out-of-pocket? No, it's listed under Deductible. It says "Structure AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." So the individual (in-network) 3200.00 might be irrelevant / not used because aggregate means only family deductible counts. But it's printed. However, maybe the 3200 individual is the "individual remainder" mentioned? Let's see accumulator addendum: "in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);" This says for embedded, smaller of member's individual remainder and family remainder. For aggregate, family remainder alone. It explicitly says member's individual remainder exists? But structure says no individual deductible under this structure. Wait "member's individual remainder" might refer to the individual deductible amount? Let's revisit.
Maybe there are two deductible thresholds: in-network: individual 3200 and family 6400. Under aggregate, the family deductible (6400) must be met before coinsurance for any member. The "individual (in-network) 3200.00" is actually an embedded individual deductible? But then it says "There is no individual deductible under this structure." Could be a typo: "There is no embedded individual deductible" meaning you don't get to satisfy an individual deductible of 3200 and then get coinsurance for that member while family not met; instead only the family aggregate 6400 matters. So the individual 3200 is just listed but not used as a separate trigger? Wait "There is no individual deductible under this structure" maybe means the plan has no individual deductible amount in the aggregate sense? Let's parse line: "Individual (in-network) ................ 3200.00 Family (in-network) .................... 6400.00 Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." This is poorly worded, but maybe they mean "There is no *embedded* individual deductible under this structure." However they say "There is no individual deductible" which conflicts with listing Individual (in-network) 3200. But the accumulator addendum says: "in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);" If there is no individual remainder (because no individual deductible), for aggregate we use family remainder alone. So the member's individual remainder is not used. Good. So in-network deductible threshold for aggregate = family remainder: family deductible 6400 - family deductible balance. So any in-network claim's deductible_applied = min(allowed, family_remaining). Once family deductible balance = 6400, deductible_applied = 0, then coinsurance 10% member.
But wait: "Out-of-network (individual) ............ 6400.00 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 a single deductible balance that combines in-network and out-of-network credits. For out-of-network claims, the threshold is the out-of-network individual amount 6400.00, measured against the member's same single deductible balance. So out-of-network deductible_applied = min(allowed, out-of-network individual remainder) where out-of-network individual remainder = 6400 - member's deductible balance (the member's single balance). Note: This member deductible balance is the running total of deductible_applied for that member, combining both networks. Also these credits accumulate to the member's balance and to the family balance. And out-of-network claims are measured against the out-of-network individual thresholds only; family amounts (6400 family in-network) do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance.
So we have:
- Family deductible balance: total of all deductible_applied across all members (both in-network and out-of-network? Actually credits from out-of-network accumulate to family balance too, yes). Family deductible threshold for in-network aggregate is 6400 (family in-network deductible). Wait Family (in-network) 6400.00. Under aggregate, for in-network claims, deductible_applied = min(allowed, family_remaining) where family_remaining = 6400 - family_balance. Once family_balance >= 6400, in-network deductible_applied = 0.
- For out-of-network claims: deductible_applied = min(allowed, OON_individual_remaining) where OON_individual_remaining = 6400 - member_balance (member's single deductible balance). Note: member_balance is the member's single deductible balance (combined). Is member_balance initially 0. Each claim adds deductible_applied to member_balance and family_balance. For out-of-network, threshold is 6400 (OON individual). Since out-of-network threshold is 6400, same as family in-network amount? Wait Family in-network is 6400. Out-of-network individual is also 6400. Interesting. So if a member has only out-of-network claims, they can apply up to 6400 of deductible credits (assuming family balance not relevant for OON because OON measured against OON individual threshold only; credits still go to family_balance but the claim's own deductible_applied is limited by member's OON individual remainder, not family remainder). For in-network claims, they apply up to family_remaining (which is 6400 - family_balance). Since family_balance includes all prior deductible credits from all members and both networks. So once family_balance hits 6400, in-network claims have 0 deductible_applied, so member pays 10% coinsurance on allowed (until OOPM). For out-of-network claims, member can continue to receive deductible credits up to their own member_balance reaching 6400 (OON individual threshold), even if family_balance already exceeded 6400? Wait family_balance would be >6400 if out-of-network credits pushed it past, because OON credits accumulate to family_balance. But the OON individual remainder is 6400 - member_balance. If member_balance < 6400, OON claim's deductible_applied = min(allowed, 6400 - member_balance). This adds to member_balance and family_balance. So family_balance can exceed 6400 due to OON claims (since balances not capped at in-network amounts). Yes: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." Wait out-of-network threshold is 6400, which is equal to family in-network amount, not higher? Actually out-of-network individual is 6400, family in-network is 6400. It says thresholds are higher. Wait OON individual 6400 vs in-network individual 3200? Yes in-network individual (listed) is 3200. Out-of-network individual is 6400, which is higher than in-network individual 3200. Family in-network is 6400. So OON individual 6400 is higher than in-network individual 3200, and equal to family in-network 6400? But family in-network aggregate is 6400. It says family balances past the family amounts (6400) due to OON. How can OON push family past 6400 if OON individual threshold is 6400? Because member_balance can reach 6400 from OON. If one member has OON claims totalling deductible_applied = 6400, then family_balance includes that 6400, so family_balance = 6400. To go past 6400, multiple members could have OON claims? Each member's OON threshold is 6400. If member A gets 6400 OON deductible credits, member_balance_A = 6400, family_balance += 6400. Then member B gets OON claims: B's member_balance starts 0, OON threshold 6400, so B can get another 6400 deductible_applied, family_balance becomes 12800, past family amount 6400. Thus family balances can exceed 6400. Yes.
Now OOPM: Out-of-pocket maximum: Individual (in-network) 7000.00, Family (in-network) 14000.00, Individual (out-of-network) 14000.00. Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for remainder of plan year. Which OOPM applies? Need interpret. The OOPM section: Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000. It says "Once a member reaches the out-of-pocket maximum the plan pays 100%..." Which threshold? For in-network services, likely the member's OOP balance is measured against...? Need parse.
From plan: "Out-of-pocket maximum
Individual (in-network) ................ 7000.00
Family (in-network) .................... 14000.00
Individual (out-of-network) ............ 14000.00
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."
Also "Member cost share: Coinsurance after deductible, in-network 10% member / 90% plan; out-of-network 40% member / 60% plan. This plan has no copays. Every covered service... subject to deductible and then coinsurance."
We need to know how OOP accumulators work. Similar to deductible? The glossary: OOPM: ceiling on member cost share for plan year. Once reached, plan pays 100% of allowed for covered in-network services. Premiums and non-covered services never count. Accumulator: running YTD total of a member's deductible or OOPM. It says "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)."
We have both individual and family OOPM. There's Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000. Need determine when member OOPM reached. Since deductible is aggregate, maybe OOPM is also aggregate? Let's read: It lists Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000. It doesn't explicitly state structure for OOPM (embedded vs aggregate). But plan document says "Out-of-pocket maximum: Individual (in-network) 7000.00, Family (in-network) 14000.00, Individual (out-of-network) 14000.00. Once a member reaches the out-of-pocket maximum the plan pays 100%..." Typically HDHP has embedded OOPM: individual OOPM inside family OOPM. But here they didn't say embedded or aggregate for OOPM. Wait they said for deductible "Structure AGGREGATE". They didn't specify OOPM structure. But they gave Individual (in-network) 7000 and Family (in-network) 14000. Also Individual (out-of-network) 14000. How to apply?
Look at accumulator addendum: It discusses balances not capped at in-network amounts for deductible. For OOP, "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." And "ending accumulators for every member and for the family" includes ending_oopm_a etc and ending_family_oopm. So we track each member's OOP balance (sum of member_responsibility for services? Yes) and family OOP balance (sum of all members' OOP). The OOP maximums: Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000. Need know thresholds met.
Typically, member cost share (member_responsibility) counts toward OOP. For in-network services, member responsibility (deductible + coinsurance) counts toward the member's OOP balance and the family OOP balance. Once the member's OOP balance reaches the individual OOP max? Or once family OOP balance reaches family OOP max? Let's parse "Once a member reaches the out-of-pocket maximum the plan pays 100%". If there is an individual OOP max of 7000 (in-network), then when a member's own OOP balance reaches 7000, that member has reached OOPM and plan pays 100% for that member's covered services (in-network). Also there is family OOP max 14000: once family OOP balance reaches 14000, maybe all members have reached OOPM? Or the family OOP max is aggregate: no member gets 100% until family OOP balance reaches 14000? But they didn't specify aggregate for OOPM. Wait given they specified aggregate only for deductible: "Structure AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." For OOPM, they didn't say aggregate. So default is likely embedded? But they gave both individual and family amounts. In standard health plan, OOPM is embedded: each individual has an individual OOPM (7000) embedded in the family OOPM (14000). If a member's OOP expenses reach 7000, that member's claims are paid at 100% (no more cost share), even if family OOP not met. And family OOPM of 14000: once total family OOP reaches 14000, all members are considered to have met OOPM. Also out-of-network individual OOPM is 14000 (since out-of-network coinsurance 40%, maybe higher max). But they also have Individual (out-of-network) 14000. Does that replace in-network individual for OON? Let's read: "Individual (out-of-network) ............ 14000.00". So out-of-network individual OOPM is 14000, which is double the in-network individual 7000, matching doubled coinsurance. There's no separate family out-of-network OOPM listed. The family (in-network) is 14000. Hmm the family OOP max is 14000 (in-network). Out-of-network individual is 14000. This is tricky.
Let's look at task: We must compute final components for Claims 19, 20, 25 and ending accumulators for every member and family. Need be very accurate.
Let's process ledger step by step. We'll track:
For each member M: member_deductible_balance (single deductible balance, combining in and out-of-network credits). Let's call m_ded.
Family deductible balance: fam_ded = sum over all claims of deductible_applied (all members). Starting 0.
For each member M: m_oop = sum of member_responsibility (deductible_applied + coinsurance? Actually member_responsibility = deductible_applied + coinsurance_amount? Let's define: For a claim, allowed = A. deductible_applied = D. Then remaining allowed after deductible = A - D. Coinsurance rate r (0.10 in-network after family ded met? Wait after deductible is satisfied, coinsurance applies to allowed ajson{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 28,721 tokens
We need answer with JSON only. Need process ledger according to plan. Need be careful.
We need final components for Claims 19, 20, 25 (adjusted for 20) and ending accumulators for each member and family. Need compute everything.
Let's restate plan specifics.
Trinity HDHP 3200 synthetic.
Plan year 2026.
Deductible:
Individual (in-network) 3200.00
Family (in-network) 6400.00
Structure: AGGREGATE — plan pays no coinsurance for any member until total family credits reach family deductible amount. There is no individual deductible under this structure.
Out-of-network (individual) 6400.00
In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above (out-of-network individual 6400?) is the threshold that balance is measured against when service is out-of-network.
Wait read carefully: Deductible section:
Individual (in-network) ................ 3200.00
Family (in-network) .................... 6400.00
Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure.
Out-of-network (individual) ............ 6400.00
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 per member? "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." For each member, there is one deductible balance that accumulates credits from both INN and OON claims. The applicable threshold depends on network:
- For in-network claims: measured against the FAMILY (aggregate) structure? Since aggregate, there is no individual deductible. The plan pays no coinsurance for any member until total family credits reach family deductible amount. How does in-network deductible_applied computed? The addendum ACCUMULATORS says:
"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);
out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."
So for in-network, threshold is family deductible (6400). Under aggregate, deductible_applied = lesser of allowed amount and the family remainder alone. Since family deductible is 6400 aggregate: no member gets coinsurance until family credits reach 6400 total. deductible_applied for an in-network claim is the amount of allowed that can be credited to family deductible before family deductible met? Wait, if aggregate family deductible: total family credits must reach 6400. Deductible_applied is the amount of allowed that goes to satisfying deductible, i.e., until family deductible met. Once family deductible met, further in-network claims have deductible_applied 0.00 and coinsurance starts (but wait plan pays no coinsurance until total family credits reach family deductible. After met, coinsurance 10% INN). Also member responsibility includes deductible_applied (toward deductible) and coinsurance? Let's parse "deductible_applied" in accumulators: A claim's deductible_applied is the lesser of allowed amount and room left under threshold that applies. Once threshold met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible. A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts. Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
Wait careful: For in-network aggregate, the threshold that applies is family deductible (6400). The "room left under the deductible threshold" is family remainder = 6400 - family deductible balance. Deductible_applied = min(allowed, family_remainder). It credits to both member's single deductible balance and family total. Since aggregate, there's no individual remainder for INN; it's family remainder alone. But the addendum also says "in-network ........ the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);" So for aggregate, use family remainder alone. Good.
But hold on: The member's single deductible balance is credited by both INN and OON. For OON claims, threshold is out-of-network individual remainder: the OON individual threshold is 6400. Measured against the member's same single deductible balance. So OON deductible_applied = min(allowed, OON_individual_remainder) where OON_individual_remainder = 6400 - member_deductible_balance (single). This OON deductible_applied credits to member's single balance and family balance. The family balance is not limited by family amounts for OON? Wait: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." So for OON, the deductible_applied depends only on member's single balance vs OON ind 6400. There is no family limit for OON credit; OON can push family balance beyond 6400 (in-network family amount) because the family balance is just sum of all credits and not capped at in-network amounts. However, for INN claims, deductible_applied depends on family remainder (6400 - family balance). If family balance already exceeded 6400 due to OON credits, then family_remainder is 0 (or negative) so min(allowed, room left) => 0? Need room left cannot be negative; if family balance >= 6400, family_remainder = 0, so deductible_applied 0.00 for further INN claims. Yes.
Need also OOPM:
Out-of-pocket max:
Individual (in-network) 7000.00
Family (in-network) 14000.00
Individual (out-of-network) 14000.00
Once a member reaches the out-of-pocket maximum the plan pays 100% of allowed for covered services for remainder of plan year.
Member cost share:
Coinsurance after deductible, in-network: 10% member / 90% plan
Coinsurance after deductible, out-of-network: 40% member / 60% plan
No copays. Every covered service subject to deductible then coinsurance. Except preventive: In-network preventive services required to be covered without cost share paid at 100% allowed, not subject to deductible/coinsurance/copay. Out-of-network preventive service is subject to OON deductible and coinsurance. (The plan says: Preventive care: In-network preventive ... paid at 100% allowed and not subject to deductible etc. And in rules: "Preventive services in-network carry no cost share and move no accumulator. An out-of-network preventive service is subject to the out-of-network deductible and coinsurance." So OON preventive is not free, subject to OON deductible and coinsurance. The ledger has:
Line 11: Claim 11 D child Annual wellness visit, out-of-network. Is annual wellness visit preventive? It says Service Annual wellness visit, out-of-network. Under plan, preventive services in-network no cost share. Out-of-network preventive service is subject to OON deductible and coinsurance. Annual wellness visit is preventive. Since OON, it's subject to OON deductible and coinsurance. Need treat as OON claim with allowed 664.62, subject to OON deductible (threshold OON ind 6400) and after deductible met 40% coinsurance. Not free.
Line 13: Claim 13 D child Screening colonoscopy, no polyp removed, out-of-network. Screening colonoscopy is preventive. OON preventive: subject to OON deductible and coinsurance. So treat as normal OON claim, not free.
Line 20: Claim 20 A subscriber Routine immunisation, in-network. Preventive in-network: paid 100%, no cost share, moves no accumulator. Wait later adjusted: ADJUSTMENT to Claim 20 lowering allowed to 745.87. Since it's preventive in-network, no cost share, no deductible, no coinsurance, no accumulators. Adjustment just changes allowed, but member responsibility 0, plan paid = allowed (745.87), deductible_applied=0, copay=0, coinsurance=0. Need process as adjustment: remove original credits (which were none because preventive), re-adjudicate at corrected values; still preventive INN, so no cost share. Plan paid equals allowed 745.87. No accumulator changes. Need check: Claim 20 originally Line 20: Service Routine immunisation, in-network. Preventive. Allowed 1243.12. Since preventive INN, member resp 0, plan paid 1243.12, deductible_applied 0, etc. At adjustment Line 23, void? No, adjustment: remove credits (none), re-adjudicate at corrected allowed 745.87. So final claim 20: member responsibility 0.00, plan paid 745.87, deductible_applied 0.00, copay 0.00, coinsurance 0.00. Ending accumulators unchanged by claim 20 (except maybe plan paid? Accumulators are deductible and OOPM, not plan paid; no change).
Need process all lines. Need also handle VOID of Claim 3 and Claim 6. Claim 3 was OON lab for C, allowed 967.99. It generated credits; at Line 14 VOID, remove its deductible credit and member responsibility from member C and family. Then later Claim 18 is another OON lab for C (allowed 593.21) processed with accumulators as they stand after void. Claim 6 was INN allergy testing for A, allowed 911.89. VOID at Line 16 removes its credits (deductible_applied and member responsibility/OOP) from A and family. Need compute what Claim 6 originally did, then remove.
Also Claim 1: A INN generic retail pharmacy fill. Allowed 74.87. No copays, subject to deductible then coinsurance. Since plan has no copays, "Generic retail pharmacy fill" is covered service subject to deductible and then coinsurance. Not preventive (it's pharmacy). So INN claim: allowed 74.87. At start family deductible balance 0, family remainder = 6400. Aggregate: deductible_applied = min(74.87, 6400) = 74.87. Member A single deductible balance becomes 74.87. Family deductible balance 74.87. OOP: member responsibility = deductible_applied + coinsurance? Wait deductible_applied is amount member pays? Let's define: Deductible is amount member pays at allowed rate before coinsurance begins. So for a claim, the portion of allowed that is applied to deductible is paid by member (member responsibility). Then after deductible, coinsurance on remaining allowed? Need compute: The allowed amount is first applied to deductible until deductible met. For the part of allowed that equals deductible_applied, member pays 100% (that's the deductible). For the remainder of allowed after deductible_applied (i.e., allowed - deductible_applied), if the deductible threshold is now met (or was already met), coinsurance applies: member pays coinsurance percentage of that remainder, plan pays the rest (for INN 90% plan / 10% member). Wait but what if deductible_applied is less than allowed because threshold met? Actually deductible_applied is the amount of allowed used to satisfy remaining deductible. The remainder allowed - deductible_applied is then subject to coinsurance, but only if after applying deductible_applied the applicable deductible threshold is met. In aggregate INN: once family deductible met (family balance >= 6400), further claims have deductible_applied 0, and entire allowed subject to coinsurance (10% member). If claim straddles: e.g., family remainder is 100, allowed is 500. Deductible_applied = 100 (credits to meet family deductible). Remaining 400: since family deductible now met, coinsurance applies to that 400: member pays 10% = 40, plan pays 90% = 360. Total member responsibility = 100 + 40 = 140. Plan paid = 360. The allowed = 500 = 140 + 360. Yes.
Similarly for OON: threshold OON individual 6400. Deductible_applied = min(allowed, OON individual remainder = 6400 - member single balance). If member balance < 6400. Once member's single balance reaches 6400 (via OON credits, because threshold is 6400), deductible_applied = 0 for further OON claims, and coinsurance OON 40% member / 60% plan applies to allowed (or remainder after deductible_applied). But careful: The addendum says out-of-network thresholds are higher, out-of-network claims can carry member's balance past the in-network individual amount, and family balances past family amounts; balances not capped. Out-of-network claims measured against OON individual thresholds only; family amounts do not limit OON claim. So for OON, if member's single balance already >= 6400 (due to prior OON credits), then OON individual remainder = 0, so deductible_applied = 0, and coinsurance 40% applies to entire allowed (since no deductible left). If member balance is, say, 6000 and OON allowed is 1000, then OON remainder = 400, deductible_applied = 400 (credits to member balance to 6400, and family balance +400). Remainder allowed 600 subject to OON coinsurance: member 40% = 240, plan 60% = 360. Member responsibility = 400 + 240 = 640. Plan paid = 360. Total allowed 1000. Note: the member's OOP max individual out-of-network is 14000, family OOP 14000 (in-network). There's also individual in-network OOP 7000. OOP balances: running total of member_responsibility (all cost share: deductible amounts paid + coinsurance). Out-of-pocket maximum: Once a member reaches the out-of-pocket maximum the plan pays 100% for remainder. There are three OOP thresholds:
- Individual (in-network) 7000.00
- Family (in-network) 14000.00
- Individual (out-of-network) 14000.00
Need interpret OOP accumulation and limits. The "family total out-of-pocket" in initial accumulators is 0. Family OOP max in-network 14000. But OOP balances: A balance is running total of member_responsibility (for an out-of-pocket balance). Ending accumulators for family: ending_family_oopm. Is family OOP balance capped at 14000? Actually OOPM is ceiling on member cost share for plan year. Once reached, plan pays 100% allowed for covered services. There is family in-network OOP 14000, and individual OON 14000. Also individual in-network 7000. Need determine how OOP max applies to claims, especially OON claims: Individual out-of-network OOP max is 14000. Does a member's OOP balance (member_responsibility running total) get compared to individual INN (7000) for INN claims, individual OON (14000) for OON claims? Or is there a single member OOP balance measured against both? The plan lists: Individual (in-network) 7000; Family (in-network) 14000; Individual (out-of-network) 14000. So likely:
- For in-network services, member cost share accumulates to individual INN OOP max of 7000, and family INN OOP max 14000. Once member's INN OOP reaches 7000, plan pays 100% for INN services (for that member). Also once family INN OOP reaches 14000, plan pays 100% for all members? Need aggregate/embedded? The structure for OOP? Not explicitly said aggregate or embedded for OOP. It just says Out-of-pocket maximum Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000. The deductible is AGGREGATE. For OOP, typical: family OOP may be aggregate or embedded? Not specified. We need infer from ledger and rules. There's member OOP balances for each member and family OOP balance. The initial accumulators show per-member out-of-pocket and family total out-of-pocket. The addendum 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 "a member reaches the out-of-pocket maximum" singular. There are three thresholds. For in-network, member reaches Individual (in-network) 7000 (or family 14000?). For OON, member reaches Individual (out-of-network) 14000. It also lists Family (in-network) 14000, so if family INN OOP aggregate reaches 14000, all members covered at 100% for INN? Need see if family OOP is aggregate or embedded. The deductible is explicitly AGGREGATE. OOP not explicitly said aggregate, but Family (in-network) 14000 is listed; typical HDHP family OOP is aggregate? But there is also individual INN OOP 7000, which suggests embedded? Wait: If family OOP is aggregate, there is usually no individual OOP, only family. But they list Individual (in-network) 7000 and Family (in-network) 14000. That suggests embedded OOP: each member has an individual INN OOP max of 7000, and family has overall INN OOP max 14000 (which can be reached by combined, and once family met, all members? Or embedded means no member pays more than 7000 INN, and family stops at 14000). But the deductible says AGGREGATE and "There is no individual deductible under this structure." For OOP, they do list individual amounts, so individual OOP exists. It doesn't say aggregate for OOP, so likely OOP is EMBEDDED? Actually it just says:
Out-of-pocket maximum
Individual (in-network) ................ 7000.00
Family (in-network) .................... 14000.00
Individual (out-of-network) ............ 14000.00
No structure label. In many plan docs, if both individual and family OOP listed, it's embedded: each individual has their own OOP max, and family OOP max is the total for the family; no individual can exceed individual max, and once family total reaches family max, everyone is at 100% (or maybe aggregate: family must meet 14000 before anyone gets 100%? But then individual INN 7000 would be meaningless because family aggregate OOP 14000 with individual? Hmm). Let's read: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered services for the remainder of the plan year. Premiums and non-covered services never count toward it." Since they list Individual (in-network) and Family (in-network), it implies there is an individual OOP max for in-network (7000) and a family OOP max for in-network (14000). For a member to reach OOPM for INN services, either their individual INN OOP hits 7000, or family INN OOP hits 14000? Usually embedded: individual OOP max applies to each member; family OOP max is aggregate of all family members' cost share, but no member can pay more than individual max (7000) toward INN; once family total reaches 14000, all family members are considered to have met OOP (plan pays 100%). Actually embedded family OOP: each member has an individual OOP max (7000 for INN, 14000 for OON? Wait OON individual 14000), and there is a family OOP max (14000 INN). Under embedded, once a member meets their individual OOP, plan pays 100% for that member. Additionally, once the family total reaches the family OOP max, all members are covered at 100% even if they haven't met individual. But if family OOP max is 14000, and individual INN is 7000, a single member could meet individual 7000 and get 100% INN coverage, while family total might be 7000; family not at 14000. If two members each have 7000, family 14000 met.
But we need know how to apply OOP to stop member responsibility. The rules: "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 "member reaches the out-of-pocket maximum" — there are different maximums depending on network? For an INN claim, the applicable OOP max is Individual (in-network) 7000 (and family 14000). For an OON claim, the applicable is Individual (out-of-network) 14000 (since family amojson{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 23,141 tokens
We need to process the ledger carefully under the plan rules. Let's restate the plan.
Plan: Trinity HDHP 3200. Plan year 2026.
Deductible:
- Individual (in-network) 3200.00
- Family (in-network) 6400.00
- Structure: AGGREGATE — plan pays no coinsurance for any member until total family credits reach family deductible amount. There is no individual deductible under this structure.
Wait, the deductible section says: "Individual (in-network) ................ 3200.00; Family (in-network) .................... 6400.00; Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
Then: "Out-of-network (individual) ............ 6400.00"
"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."
Hold on: There is a single member deductible balance. But the structure says AGGREGATE for in-network? Let's parse.
Under the plan document Deductible:
- Individual (in-network) 3200.00
- Family (in-network) 6400.00
- Structure AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure.
- Out-of-network (individual) 6400.00
- 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: The "AGGREGATE" structure says there is no individual deductible under this structure. But then there is an "Out-of-network (individual) 6400.00" threshold. And out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim.
We need to carefully interpret the rules from the Plan Document + Addendum (ACCUMULATORS).
Let's read ACCUMULATORS addendum:
"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);
out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance.
Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible.
A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts.
Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
Also from rules for whole 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. Under an aggregate structure no member reaches coinsurance until the family amount is met."
Wait, under aggregate structure no member reaches coinsurance until the family amount is met. Since the structure is AGGREGATE, in-network claims: deductible_applied is the family remainder alone (aggregate). That is: for in-network claims, the deductible threshold that applies is the family deductible (6400.00) and the room left is family remainder? Actually "the family remainder alone (aggregate)". So for in-network, deductible_applied = min(allowed amount, family_remainder). But wait, the members have their own single deductible balance. The balance is a running total of deductible_applied. The family total deductible is the sum? Or is it tracked as an aggregate family accumulator? The initial accumulators list:
A deductible 0.00, B 0.00, C 0.00, D 0.00, E 0.00, Family total deductible 0.00.
So each member has a deductible accumulator (balance). And a family total deductible accumulator. The family total is the sum of member balances? It says "Family total deductible 0.00" and "A member's own accumulator and the family accumulator both move on every claim that generates cost share." So family accumulator moves by the same deductible_applied amount? Or family total is sum of members? Let's check: "ending accumulators for every member and for the family." And initial: "Family total deductible 0.00". If each member moves by deductible_applied and family moves by deductible_applied as well, then family total = sum of member balances (since each credit adds to member and family). Yes.
Now, the thresholds:
- In-network: threshold is family deductible 6400.00, structure AGGREGATE. So the applicable threshold for in-network claims is the family amount 6400.00. The room left under the deductible threshold is "the family remainder alone (aggregate)". That means family_remainder = max(0, 6400.00 - family_deductible_balance). Since it's aggregate, we DO NOT use member's individual remainder (3200.00) for in-network? The addendum says: "in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);". Since structure is AGGREGATE, we use "the family remainder alone". So for in-network, deductible_applied = min(allowed, family_remainder). And once the family threshold (6400) is met, deductible_applied = 0.00. Because "Once the applicable threshold is met, deductible_applied is 0.00". The applicable threshold for in-network is the family deductible (6400). Wait, but the plan says "Individual (in-network) ................ 3200.00; Family (in-network) .................... 6400.00; Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." Yes! So under aggregate, there is NO individual in-network deductible. All in-network claims just go to the family deductible of 6400. Once family deductible balance reaches 6400, in-network deductible_applied = 0 and coinsurance (10% member) starts. There is no individual 3200 for in-network. The 3200 individual is listed but structure says there is no individual deductible under this structure. So ignore 3200 for in-network? Actually it's listed as "Individual (in-network) 3200.00" but then "Structure AGGREGATE ... There is no individual deductible under this structure." Wait, that's contradictory: it lists Individual (in-network) 3200.00, then says there is no individual deductible under this structure. The addendum clarifies: for in-network embedded, you use smaller of member's individual remainder and family remainder; for aggregate, you use family remainder alone. Since structure is aggregate, the member's individual remainder (which would be 3200 minus member balance?) is not used for in-network. The "Individual (in-network) 3200" is perhaps the embedded amount but since structure is aggregate it's not used? Let's be precise.
Plan says:
Deductible
Individual (in-network) ................ 3200.00
Family (in-network) .................... 6400.00
Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure.
Out-of-network (individual) ............ 6400.00
So for in-network, the deductible threshold is the family deductible amount 6400.00 under aggregate. There is no individual deductible (the 3200 is not an individual deductible that can be satisfied; it's just the embedded individual amount in a different structure). The out-of-network threshold is individual 6400.00. Out-of-network claims are measured against out-of-network individual threshold only (6400.00), using the member's single deductible balance. The member's single deductible balance accumulates both in-network and out-of-network deductible_applied credits.
Now, out-of-pocket maximum:
Individual (in-network) 7000.00
Family (in-network) 14000.00
Individual (out-of-network) 14000.00
"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."
This says "Once a member reaches the out-of-pocket maximum". Which out-of-pocket maximum? There is Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000. Does a member have an OOPM threshold? Usually under ACA, individual OOPM for in-network is 7000, family 14000. Out-of-network individual OOPM is 14000. The addendum says: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." Also "A balance is the running total of ... member_responsibility (for an out-of-pocket balance)." And "Once a member reaches the out-of-pocket maximum the plan pays 100%". Which maximum? The member's out-of-pocket balance? We must check if the member's OOP balance hitting 7000 (in-network individual) stops cost share for in-network? And hitting 14000 (out-of-network individual) stops cost share for out-of-network? Or is it a single combined balance? The plan says "Individual (in-network) ................ 7000.00; Family (in-network) .................... 14000.00; Individual (out-of-network) ................ 14000.00". So there are separate thresholds: in-network individual OOPM is 7000, family in-network OOPM is 14000. Out-of-network individual OOPM is 14000. Does a member have both an in-network OOP balance and an out-of-network OOP balance? The initial accumulators show: each member has "deductible" and "out-of-pocket" (only one OOP accumulator per member). And family total has "deductible" and "out-of-pocket". So there is a SINGLE out-of-pocket accumulator per member (and family) that tracks member_responsibility (cost share) from all claims? Wait, the ledger initial: "A (subscriber) deductible 0.00 out-of-pocket 0.00". It's a single out-of-pocket accumulator. But the plan has different thresholds: in-network individual OOPM 7000, out-of-network individual OOPM 14000. And family in-network OOPM 14000. So how do thresholds apply to a single balance?
The rule: "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." Which OOPM? It likely refers to the applicable OOPM for the service/network. For in-network services, once the member's OOP balance reaches the in-network individual OOPM? Or the family in-network OOPM? Actually, cost share for in-network: deductible (family aggregate 6400) then 10% coinsurance. The member's individual in-network OOPM is 7000. The family in-network OOPM is 14000. Since this is a family plan, embedded or aggregate for OOPM? The plan document doesn't specify structure for OOPM. It just lists Individual (in-network) 7000, Family (in-network) 14000. Usually, family plans have an embedded individual OOPM (7000) and a family OOPM (14000). But we need to see the addendum. The addendum says: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This implies the same OOP balance (member_responsibility) is compared to thresholds: in-network individual amount (7000) and family amounts (family in-network 14000). And out-of-network claims can carry the balance past the in-network individual amount (7000) and past the family amounts (14000) because out-of-network individual OOPM is 14000. So once the member's OOP balance reaches 7000 (in-network individual OOPM), do they stop paying for in-network services? And once balance reaches 14000 (out-of-network individual OOPM), do they stop paying for out-of-network services? And for family, once family OOP balance reaches 14000 (family in-network OOPM), do all members stop paying for in-network? What about out-of-network family? There is no out-of-network family OOPM listed; only Individual (out-of-network) 14000. The addendum says out-of-network thresholds are higher (14000 vs 7000 in-network individual). So for out-of-network, the member's same OOP balance is measured against 14000 (out-of-network individual OOPM) to stop out-of-network cost share. For in-network, the member's OOP balance is measured against 7000 (in-network individual OOPM) to stop in-network cost share? And family in-network OOPM is 14000 to stop in-network cost share for all members? Let's assume embedded OOPM: individual 7000, family 14000. When member's OOP reaches 7000, that member's in-network cost share stops (plan pays 100%). When family OOP reaches 14000, all members' in-network cost share stops. For out-of-network, individual OOPM is 14000; when member's OOP balance reaches 14000, out-of-network cost share stops for that member. There is no family out-of-network OOPM, so family OOP (14000 in-network) doesn't stop out-of-network? Actually addendum: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." This was stated for deductible: "the family amounts, which are in-network amounts, do not limit an out-of-network claim." It likely also applies to OOPM: family in-network OOPM (14000) does not limit out-of-network claims; out-of-network claims are measured against out-of-network individual OOPM (14000). So for out-of-network, the member's OOP balance is compared to 14000. Once member OOP balance >= 14000, out-of-network cost share is 0 (plan pays 100%). But wait, the OOP balance is a single balance. If a member has high out-of-network cost share, their OOP balance can exceed 7000. Once it exceeds 7000, they have already met the in-network individual OOPM (7000), so all their in-network services should be paid at 100% (no cost share). And once it hits 14000, out-of-network services are also paid at 100%. Does hitting 14000 also mean family in-network OOPM is met (since family in-network is 14000)? The family OOP total is the sum of member OOP balances. If family total reaches 14000, all members' in-network cost share stops. But out-of-network is per member 14000.
Let's verify with typical rules: 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 " applicable to that network". But the addendum says out-of-network claims can carry a member's balance past the in-network individual amount (7000) and the family balances past the family amounts (14000); the balances are not capped at the in-network amounts. This means if member OOP balance is, say, 8000 (due to out-of-network), they have passed 7000, so they have reached the in-network individual OOPM. Thus for subsequent IN-NETWORK services, plan pays 100% (no deductible, no coinsurance). But for OUT-OF-NETWORK services, they have not reached 14000 yet (out-of-network individual OOPM), so they still pay out-of-network coinsurance (40%) until balance hits 14000. That makes sense.
Now, deductible_applied and cost share calculation:
For each claim, we need to determine network, allowed amount.
If preventive in-network: cost share zero, no accumulators move. If preventive out-of-network: subject to out-of-network deductible and coinsurance.
What services are preventive?
- Line 11: Annual wellness visit, out-of-network. Is an annual wellness visit preventive? Yes, annual wellness visit is a preventive service. But it is OUT-OF-NETWORK. Rule: "Preventive services in-network carry no cost share and move no accumulator. An out-of-network preventive service is subject to the out-of-network deductible and coinsurance." So Line 11 is preventive but out-of-network, so it IS subject to out-of-network deductible and coinsurance.
- Line 13: Screening colonoscopy, no polyp removed, out-of-network. Screening colonoscopy is preventive (USPSTF). But out-of-network, so subject to out-of-network deductible and coinsurance.
- Line 20: Routine immunisation, in-network. Preventive, in-network -> no cost share, no accumulators move. Wait, but Line 23 adjusts Claim 20 (allowed corrected downward). Claim 20 was routine immunisation in-network. Preventive in-network: no cost share, no deductible, no coinsurance. So its components are all 0.00? Let's check: "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." So for Claim 20, member responsibility = 0.00, plan_paid = allowed (1243.12 originally, then adjusted to 745.87). Deductible_applied = 0.00, copay = 0.00 (no copays anyway), coinsurance = 0.00. And since it moves no accumulator, adjustment of Claim 20: we unwind the original Claim 20 credits. Original Claim 20 had no credits (deductible 0, OOP 0). So unwinding does nothing. Then re-adjudicate at corrected allowed 745.87: still preventive in-network, so all components 0.00, plan_paid = 745.87. So Claim 20 final: member_responsibility 0.00, plan_paid 745.87, deductible_applied 0.00, copay 0.00, coinsurance 0.00. Wait, the task asks for claim_20 components. Since it was adjusted, report components from adjustment. They should be zero member responsibility, plan paid = 745.87. Need to ensure plan_paid is allowed amount (745.87). Yes.
Now let's process all lines sequentially. We'll track per member: deductible balance (DedBal), OOP balance (OOPBal). And family: FamDed, FamOOP.
Initial: All 0.
Thresholds:
IN-NETWORK:
- Deductible threshold: Aggregate, family deductible = 6400.00. So in-network deductible_applied = min(allowed, max(0, 6400 - FamDed)). Note: FamDed is the family deductible accumulator (sum of all member deductible balances). Wait, is FamDed the family accumulator that moves? Yes. Initially 0. When a member gets deductible_applied, member DedBal increases by deductible_applied, and FamDed increases by deductible_applied. Since it's aggregate, we check FamDed against 6400. Once FamDed >= 6400, in-network deductible_applied = 0.
- After deductible (i.e., for the remainder of allowed after deductible_applied), coinsurance: 10% member, 90% plan. But OOP max: For in-network, member's OOP balance after adding member_responsibility is compared to 7000 (individual in-network OOPM). And family OOP compared to 14000 (family in-network OOPM). How to apply OOPM? "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 means when calculating a claim, if the member has already met their OOPM (OOPBal >= applicable threshold), then member_responsibility = 0 and plan_paid = allowed. But if they meet it DURING the claim, we must calculate the cost share but cap the member responsibility so that the running OOP balance does not exceed the threshold. Specifically, the member pays the cost share (deductible + coinsurance) but only up to the OOPM. Once Ojson{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.14
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.14,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}67Claude Sonnet 5 · Anthropic214.3s · 24,845 out | 150.7s · 17,878 out | 175.4s · 20,859 out
Reasoning · 24,325 tokens
[omitted]json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "462.07",
"ending_oopm_a": "842.12",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8193.58",
"ending_deductible_d": "935.83",
"ending_oopm_d": "2833.35",
"ending_deductible_e": "91.19",
"ending_oopm_e": "91.19",
"ending_family_deductible": "7919.28",
"ending_family_oopm": "14000.00"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "462.07",
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "842.12",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8193.58",
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "935.83",
"ok": false,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "2833.35",
"ok": false,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "91.19",
"ok": false,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "91.19",
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "7919.28",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "14000.00",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}Reasoning · 17,351 tokens
[omitted]json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.13",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 20,332 tokens
[omitted]json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.14"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.14",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}67Qwen3.7 Max · Alibaba331.6s · 23,431 out | 442.3s · 30,000 out | 264.1s · 18,639 out
Reasoning · 22,934 tokens
Let me process this step by step.
Plan: Trinity HDHP 3200
- Aggregate deductible: Family must meet $6400 before any coinsurance kicks in.
- Individual deductible: $3200 (but under aggregate structure, no individual deductible - family amount must be met first)
- Wait, re-reading: "Structure: AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
- So the family deductible is $6400. All members' deductible credits accumulate toward this $6400 family deductible.
- Out-of-network individual deductible: $6400
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance.
Wait, let me re-read the deductible section:
- Individual (in-network): $3200
- Family (in-network): $6400
- Structure: AGGREGATE - no individual deductible, family amount must be met
- Out-of-network (individual): $6400
- "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
So under aggregate, the family deductible is $6400. All deductible credits from all members go toward this $6400.
For out-of-network claims: "out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."
Wait, but under aggregate structure, there's no individual deductible. Let me re-read the accumulator rules:
"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);
out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."
So for in-network under aggregate: deductible_applied = lesser of allowed amount and family remainder.
For out-of-network: deductible_applied = lesser of allowed amount and out-of-network individual remainder (which is $6400 minus the member's single deductible balance).
Wait, but the member's single deductible balance includes both in-network and out-of-network credits. So the out-of-network individual threshold is $6400, measured against the member's total deductible balance.
Let me re-read: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
So out-of-network claims:
- deductible_applied = lesser of allowed amount and ($6400 - member's single deductible balance)
- The credits still go to family balance too.
For in-network claims under aggregate:
- deductible_applied = lesser of allowed amount and family remainder ($6400 - family deductible balance)
- No individual deductible applies.
Once the applicable deductible is met, coinsurance applies:
- In-network: 10% member / 90% plan
- Out-of-network: 40% member / 60% plan
OOPM:
- Individual (in-network): $7000
- Family (in-network): $14000
- Individual (out-of-network): $14000
"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 tracks member_responsibility. Once member's OOPM is reached, plan pays 100%.
Wait, I need to think about how OOPM works with family. The plan says:
- Individual (in-network): $7000
- Family (in-network): $14000
- Individual (out-of-network): $14000
Does this plan have embedded OOPM? The plan document doesn't explicitly say "embedded" or "aggregate" for OOPM. Let me check...
The plan document says:
"Out-of-pocket maximum
Individual (in-network) ................ 7000.00
Family (in-network) .................... 14000.00
Individual (out-of-network) ............ 14000.00
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 aggregate or embedded for OOPM. Let me think about this. The deductible is explicitly AGGREGATE. The OOPM doesn't say. Usually in health plans, if there's an individual and family OOPM, it's embedded (individual can max out on their own). But the plan doesn't explicitly say.
Wait, let me re-read the glossary:
"Embedded deductible: an individual deductible inside a family deductible; the individual amount can be satisfied on its own."
"Aggregate deductible: the family amount must be satisfied in full before the plan pays for any member."
These are defined for deductibles. For OOPM, the standard approach would be embedded unless stated otherwise. But let me look at the accumulator rules again:
"A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)."
"Once the applicable threshold is met, deductible_applied is 0.00"
"Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
I think the OOPM works similarly to the deductible structure unless specified. Since the deductible is aggregate, maybe OOPM is also aggregate? But the plan doesn't say that explicitly.
Actually, looking at the plan document more carefully, it says "Once a member reaches the out-of-pocket maximum" - this implies individual tracking. If it were aggregate, it would say "once the family reaches." I'll assume embedded OOPM (individual $7000 in-network, family $14000 in-network).
Wait, but I need to be more careful. Let me think about what "embedded" means for OOPM:
- Each member has an individual OOPM of $7000 (in-network)
- The family has a family OOPM of $14000 (in-network)
- When a member's individual OOPM is reached, plan pays 100% for that member
- When the family OOPM is reached, plan pays 100% for all members
For out-of-network, individual OOPM is $14000. There's no family out-of-network OOPM mentioned.
Let me think about how in-network and out-of-network OOPM interact. The plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." Does the same apply to OOPM?
The plan doesn't explicitly say OOPM credits accumulate to a single balance. Let me assume they're separate based on the plan document listing them separately:
- Individual (in-network): $7000
- Family (in-network): $14000
- Individual (out-of-network): $14000
Actually wait, re-reading: "the family amounts, which are in-network amounts, do not limit an out-of-network claim." This is about deductibles. For OOPM, the family OOPM is $14000 (in-network).
I think the safest interpretation is:
- Member responsibility from in-network claims accumulates toward the individual in-network OOPM ($7000) and the family in-network OOPM ($14000).
- Member responsibility from out-of-network claims accumulates toward the individual out-of-network OOPM ($14000).
- But do they share a single balance? The plan doesn't say they do for OOPM like it does for deductible.
Actually, let me re-read the accumulator addendum: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)."
It says "a balance" - singular. This might mean there's one OOPM balance per member. But the plan lists separate in-network and out-of-network OOPM thresholds.
Hmm, let me think about this differently. The deductible section explicitly says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." The OOPM section does NOT say this. So maybe OOPM has separate in-network and out-of-network balances?
But then "the family amounts, which are in-network amounts, do not limit an out-of-network claim" - this is about deductibles.
I think the most reasonable interpretation given the plan document is:
- There's a single member OOPM balance (like the deductible)
- In-network claims are measured against: individual in-network OOPM ($7000) and family in-network OOPM ($14000)
- Out-of-network claims are measured against: individual out-of-network OOPM ($14000)
- Family OOPM is in-network only ($14000)
Actually, I think I'm overcomplicating this. Let me re-read the plan:
"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."
I think the OOPM works like this:
- For in-network services: once member's in-network OOPM balance reaches $7000, plan pays 100% of in-network allowed amounts.
- For out-of-network services: once member's out-of-network OOPM balance reaches $14000, plan pays 100% of out-of-network allowed amounts.
- Family OOPM ($14000 in-network): once family's total in-network member responsibility reaches $14000, plan pays 100% for all members' in-network services.
But wait, do in-network and out-of-network member responsibilities accumulate to the same OOPM balance? The plan doesn't say they do for OOPM. Let me assume they're separate since the thresholds are different and the plan doesn't say they combine.
Actually, re-reading the accumulator rules: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
This talks about "a member's balance" - singular. This suggests a single balance that is measured against different thresholds depending on whether the claim is in-network or out-of-network.
So I think the OOPM works like this:
- Single member OOPM balance (sum of all member responsibilities)
- For in-network claims: check if member's balance has reached $7000 (individual) or family balance has reached $14000
- For out-of-network claims: check if member's balance has reached $14000
Similarly for deductible:
- Single member deductible balance
- For in-network claims (aggregate): check family balance against $6400
- For out-of-network claims: check member's balance against $6400
Wait, but that creates a problem. If the family deductible is $6400 and the out-of-network individual deductible is also $6400, and they share the same balance... 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."
OK so for deductible:
- Single member deductible balance (all credits go here)
- Family deductible balance (sum of all members' deductible credits)
- For in-network claims (aggregate): deductible_applied = lesser of allowed and ($6400 - family deductible balance)
- For out-of-network claims: deductible_applied = lesser of allowed and ($6400 - member's deductible balance)
Wait, but the out-of-network individual deductible is $6400 and the family deductible is also $6400. Under aggregate, for in-network, the family must meet $6400 before any coinsurance. For out-of-network, the individual must meet $6400.
So if member A has $3000 in deductible credits (from in-network claims), and then has an out-of-network claim, the out-of-network deductible remainder is $6400 - $3000 = $3400.
For the family deductible (aggregate), all members' credits count. So if A has $3000 and B has $2000, family deductible balance is $5000, and the family remainder is $6400 - $5000 = $1400 for in-network claims.
Let me now think about OOPM similarly:
- Single member OOPM balance
- For in-network: individual threshold $7000, family threshold $14000
- For out-of-network: individual threshold $14000
Since the plan says "Once a member reaches the out-of-pocket maximum the plan pays 100%", I think:
- For in-network: once member's OOPM balance reaches $7000 OR family OOPM balance reaches $14000, plan pays 100% for that member's in-network claims.
- For out-of-network: once member's OOPM balance reaches $14000, plan pays 100% for that member's out-of-network claims.
Wait, but do in-network and out-of-network member responsibilities accumulate to the same OOPM balance? The plan doesn't explicitly say so for OOPM. But the accumulator rules say "a member's balance" singular, and "the balances are not capped at the in-network amounts."
I'll assume single OOPM balance per member, and single family OOPM balance, with different thresholds for in-network vs out-of-network.
Let me also think about the family OOPM. Is it embedded or aggregate? The plan doesn't say. Given the deductible is aggregate, maybe OOPM is also aggregate? But "Once a member reaches the out-of-pocket maximum" suggests individual tracking. I'll assume embedded OOPM (individual can max out on their own, and family can max out).
Actually, for OOPM, embedded is the standard and most common structure. The plan doesn't say aggregate for OOPM. Let me go with embedded.
So for in-network OOPM:
- Member's OOPM balance measured against $7000
- Family's OOPM balance measured against $14000
- If either is met, plan pays 100% for that member's in-network claims
For out-of-network OOPM:
- Member's OOPM balance measured against $14000
- No family out-of-network OOPM mentioned
Let me now process the ledger.
Initial state:
- A: deductible=0, OOPM=0
- B: deductible=0, OOPM=0
- C: deductible=0, OOPM=0
- D: deductible=0, OOPM=0
- E: deductible=0, OOPM=0
- Family: deductible=0, OOPM=0
**Line 1 — Claim 1 — 2026-01-07 — A (subscriber)**
- Generic retail pharmacy, in-network
- Allowed: $74.87
- In-network, aggregate deductible: family remainder = $6400 - 0 = $6400
- deductible_applied = min($74.87, $6400) = $74.87
- No coinsurance yet (family deductible not met)
- member_responsibility = $74.87 (all goes to deductible)
- plan_paid = $0.00
- coinsurance_amount = $0.00
- copay_amount = $0.00
Update accumulators:
- A: deductible=74.87, OOPM=74.87
- Family: deductible=74.87, OOPM=74.87
**Line 2 — Claim 2 — 2026-01-17 — C (child)**
- Inpatient admission, out-of-network
- Allowed: $10883.95
- Out-of-network: member C's deductible balance = 0, out-of-network individual remainder = $6400 - 0 = $6400
- deductible_applied = min($10883.95, $6400) = $6400.00
- Remaining after deductible: $10883.95 - $6400 = $4483.95
- Coinsurance (out-of-network, 40% member): $4483.95 * 0.40 = $1793.58
- Member responsibility = deductible_applied + coinsurance = $6400 + $1793.58 = $8193.58
- Plan paid = $4483.95 * 0.60 = $2690.37
Wait, let me check OOPM. Member C's OOPM balance before this claim = 0. Out-of-network OOPM threshold = $14000.
Member responsibility for this claim = $8193.58. This doesn't exceed $14000, so no OOPM cap.
Actually wait, I need to think about whether the OOPM cap applies during this claim. The member's OOPM balance is 0, and the member responsibility would be $8193.58. Since 0 + $8193.58 = $8193.58 < $14000, no cap needed.
Update accumulators:
- C: deductible = 0 + 6400 = 6400.00, OOPM = 0 + 8193.58 = 8193.58
- Family: deductible = 74.87 + 6400 = 6474.87, OOPM = 74.87 + 8193.58 = 8268.45
Wait, family deductible is now $6474.87, which exceeds $6400. So family deductible is met.
**Line 3 — Claim 3 — 2026-02-01 — C (child)**
- Diagnostic laboratory panel, out-of-network
- Allowed: $967.99
- Out-of-network: C's deductible balance = 6400, out-of-network individual remainder = $6400 - $6400 = $0
- deductible_applied = min($967.99, $0) = $0.00
- Remaining: $967.99
- Coinsurance (out-of-network, 40%): $967.99 * 0.40 = $387.196 = $387.20
- Member responsibility = $0 + $387.20 = $387.20
Check OOPM: C's OOPM balance = 8193.58. Out-of-network threshold = $14000.
8193.58 + 387.20 = 8580.78 < 14000. No cap.
- Plan paid = $967.99 * 0.60 = $580.79 (wait, $967.99 - $387.20 = $580.79)
Actually, let me recalculate: $967.99 * 0.40 = $387.196. Round half up to cent: $387.20.
$967.99 * 0.60 = $580.794. Round half up to cent: $580.79.
Check: $387.20 + $580.79 = $967.99. Yes.
Update accumulators:
- C: deductible = 6400.00, OOPM = 8193.58 + 387.20 = 8580.78
- Family: deductible = 6474.87, OOPM = 8268.45 + 387.20 = 8655.65
**Line 4 — Claim 4 — 2026-02-15 — A (subscriber)**
- Urgent care visit, in-network
- Allowed: $255.34
- In-network, aggregate: family deductible balance = 6474.87, family remainder = $6400 - $6474.87 = negative, so 0
- deductible_applied = min($255.34, 0) = $0.00
- Family deductible is met, so coinsurance applies.
- Coinsurance (in-network, 10%): $255.34 * 0.10 = $25.534 = $25.53
- Member responsibility = $0 + $25.53 = $25.53
- Plan paid = $255.34 * 0.90 = $229.806 = $229.81
- Check: $25.53 + $229.81 = $255.34. Yes.
Check OOPM: A's OOPM balance = 74.87. In-network individual threshold = $7000.
74.87 + 25.53 = 100.40 < 7000. No cap.
Family OOPM balance = 8655.65. Family in-network threshold = $14000.
8655.65 + 25.53 = 8681.18 < 14000. No cap.
Update accumulators:
- A: deductible = 74.87, OOPM = 74.87 + 25.53 = 100.40
- Family: deductible = 6474.87, OOPM = 8655.65 + 25.53 = 8681.18
**Line 5 — Claim 5 — 2026-03-01 — A (subscriber)**
- Emergency department visit, in-network
- Allowed: $3545.18
- In-network, aggregate: family deductible met, so deductible_applied = $0.00
- Coinsurance (in-network, 10%): $3545.18 * 0.10 = $354.518 = $354.52
- Member responsibility = $354.52
- Plan paid = $3545.18 * 0.90 = $3190.662 = $3190.66
- Check: $354.52 + $3190.66 = $3545.18. Yes.
Check OOPM: A's OOPM = 100.40 + 354.52 = 454.92 < 7000.
Family OOPM = 8681.18 + 354.52 = 9035.70 < 14000.
Update accumulators:
- A: deductible = 74.87, OOPM = 454.92
- Family: deductible = 6474.87, OOPM = 9035.70
**Line 6 — Claim 6 — 2026-03-07 — A (subscriber)**
- Allergy testing, in-network
- Allowed: $911.89
- In-network, aggregate: family deductible met, deductible_applied = $0.00
- Coinsurance (in-network, 10%): $911.89 * 0.10 = $91.189 = $91.19
- Member responsibility = $91.19
- Plan paid = $911.89 * 0.90 = $820.701 = $820.70
- Check: $91.19 + $820.70 = $911.89. Yes.
Check OOPM: A's OOPM = 454.92 + 91.19 = 546.11 < 7000.
Family OOPM = 9035.70 + 91.19 = 9126.89 < 14000.
Update accumulators:
- A: deductible = 74.87, OOPM = 546.11
- Family: deductible = 6474.87, OOPM = 9126.89
**Line 7 — Claim 7 — 2026-03-19 — B (spouse)**
- Ambulatory surgery, in-network
- Allowed: $7845.50
- In-network, aggregate: family deductible met, deductible_applied = $0.00
- Coinsurance (in-network, 10%): $7845.50 * 0.10 = $784.55
- Member responsibility = $784.55
- Plan paid = $7845.50 * 0.90 = $7060.95
- Check: $784.55 + $7060.95 = $7845.50. Yes.
Check OOPM: B's OOPM = 0 + 784.55 = 784.55 < 7000.
Family OOPM = 9126.89 + 784.55 = 9911.44 < 14000.
Update accumulators:
- B: deductible = 0.00, OOPM = 784.55
- Family: deductible = 6474.87, OOPM = 9911.44
**Line 8 — Claim 8 — 2026-03-28 — D (child)**
- Ambulatory surgery, in-network
- Allowed: $6750.63
- In-network, aggregate: family deductible met, deductible_applied = $0.00
- Coinsurance (in-network, 10%): $6750.63 * 0.10 = $675.063 = $675.06
- Member responsibility = $675.06
- Plan paid = $6750.63 * 0.90 = $6075.567 = $6075.57
- Check: $675.06 + $6075.57 = $6750.63. Yes.
Check OOPM: D's OOPM = 0 + 675.06 = 675.06 < 7000.
Family OOPM = 9911.44 + 675.06 = 10586.50 < 14000.
Update accumulators:
- D: deductible = 0.00, OOPM = 675.06
- Family: deductible = 6474.87, OOPM = 10586.50
**Line 9 — Claim 9 — 2026-04-11 — B (spouse)**
- Inpatient admission, in-network
- Allowed: $12250.27
- In-network, aggregate: family deductible met, deductible_applied = $0.00
- Coinsurance (in-network, 10%): $12250.27 * 0.10 = $1225.027 = $1225.03
- Member responsibility = $1225.03
- Plan paid = $12250.27 * 0.90 = $11025.243 = $11025.24
- Check: $1225.03 + $11025.24 = $12250.27. Yes.
Check OOPM:json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 30,000 tokens
Let me carefully process each claim line by line, tracking accumulators for each member and the family.
Plan details:
- Deductible: Individual 3200, Family 6400, AGGREGATE structure
- Out-of-network deductible (individual): 6400
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance
- OOPM: Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000
- Coinsurance after deductible, in-network: 10% member / 90% plan
- Coinsurance after deductible, out-of-network: 40% member / 60% plan
- No copays
- Preventive care in-network: 100% paid, no cost share, no deductible credit
AGGREGATE structure: "the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
So the family deductible is 6400. No member gets coinsurance until the family deductible (6400) is met.
Wait, let me re-read: "the plan pays no coinsurance for any member until total family credits reach the family deductible amount."
And for deductible_applied:
- in-network: "the family remainder alone (aggregate)"
- out-of-network: "the out-of-network individual remainder, measured against the member's same single deductible balance"
So for in-network claims, deductible_applied is the lesser of the allowed amount and the family remainder.
For out-of-network claims, deductible_applied is the lesser of the allowed amount and the out-of-network individual remainder (6400 minus the member's single deductible balance).
Wait, but the family deductible is 6400 and the out-of-network individual deductible is also 6400. Let me re-read.
"Deductible
Individual (in-network) ................ 3200.00
Family (in-network) .................... 6400.00
Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure.
Out-of-network (individual) ............ 6400.00
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 in-network: family deductible is 6400. Since aggregate, no individual deductible. Deductible_applied = lesser of allowed amount and family remainder.
- For out-of-network: individual deductible is 6400. Measured against the member's single deductible balance (which includes both in-network and out-of-network credits).
Wait, but how does the family deductible interact with out-of-network? Let me re-read the accumulator rules:
"Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
So out-of-network claims:
- Deductible_applied = lesser of allowed amount and (6400 - member's single deductible balance)
- These credits also add to the family deductible balance
And for in-network claims:
- Deductible_applied = lesser of allowed amount and (family deductible remainder)
- But wait, in aggregate structure, does the member's own balance matter? Let me re-read.
"in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate)"
So for aggregate: deductible_applied for in-network = lesser of allowed amount and family remainder.
But what about the member's own deductible balance? In aggregate, there is no individual deductible. So the member's balance just tracks credits but doesn't limit anything for in-network.
Actually wait - for out-of-network, the threshold is 6400 for the individual. So a member needs their own single deductible balance to reach 6400 before they get coinsurance on out-of-network services.
For in-network, the family deductible is 6400 (aggregate). Once the family total reaches 6400, all members get coinsurance on in-network services.
Let me also think about OOPM:
- Individual (in-network): 7000
- Family (in-network): 14000
- Individual (out-of-network): 14000
OOPM tracks member_responsibility. Once a member's OOPM is reached, plan pays 100%.
For in-network, member's OOPM is 7000. Family OOPM is 14000.
For out-of-network, member's OOPM is 14000.
Wait, but there's only one OOPM balance per member? Or separate in-network and out-of-network?
The plan says:
"Out-of-pocket maximum
Individual (in-network) ................ 7000.00
Family (in-network) .................... 14000.00
Individual (out-of-network) ............ 14000.00"
And the accumulator rules say: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)."
I think there's a single OOPM balance per member, and it's measured against different thresholds depending on network status. Similar to how the deductible works - single balance, different thresholds.
Actually wait, let me re-read: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
So there's a single OOPM balance per member. For in-network services, it's measured against 7000 (individual) and 14000 (family). For out-of-network, it's measured against 14000 (individual).
Hmm, but actually, I need to think about this more carefully. When does a member reach OOPM for in-network? When their member_responsibility total reaches 7000. For out-of-network? When their member_responsibility total reaches 14000.
So if a member has accumulated 6500 in member_responsibility, they haven't reached either OOPM. If they then have an in-network claim, they could be capped at 7000. If out-of-network, they continue until 14000.
Let me also consider the family OOPM. "Family (in-network) 14000". So once the family total of member_responsibility reaches 14000, all members get 100% for in-network.
OK let me now process each claim.
INITIAL STATE:
A: ded=0, oopm=0
B: ded=0, oopm=0
C: ded=0, oopm=0
D: ded=0, oopm=0
E: ded=0, oopm=0
Family: ded=0, oopm=0
---
LINE 1: Claim 1 — 2026-01-07 — A (subscriber)
Generic retail pharmacy, in-network
Allowed: 74.87
In-network, aggregate structure.
Family deductible remainder = 6400 - 0 = 6400
Deductible_applied = min(74.87, 6400) = 74.87
All goes to deductible.
Member responsibility = 74.87
Plan paid = 0.00
A: ded = 0 + 74.87 = 74.87, oopm = 0 + 74.87 = 74.87
Family: ded = 0 + 74.87 = 74.87, oopm = 0 + 74.87 = 74.87
---
LINE 2: Claim 2 — 2026-01-17 — C (child)
Inpatient admission, out-of-network
Allowed: 10883.95
Out-of-network.
C's single deductible balance = 0
Out-of-network individual deductible = 6400
C's deductible remainder = 6400 - 0 = 6400
Deductible_applied = min(10883.95, 6400) = 6400.00
Remaining after deductible = 10883.95 - 6400 = 4483.95
Coinsurance (out-of-network, 40% member): 4483.95 * 0.40 = 1793.58
Plan coinsurance: 4483.95 * 0.60 = 2690.37
Member responsibility = deductible_applied + coinsurance = 6400 + 1793.58 = 7793.58
Plan paid = 2690.37
Wait, but does the family deductible also get credited? "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
So C's ded balance: 0 + 6400 = 6400
Family ded balance: 74.87 + 6400 = 6474.87
Wait, the family deductible is 6400. So family ded is now 6474.87, which exceeds 6400. That's fine, balances are not capped.
C's oopm: 0 + 7793.58 = 7793.58
Family oopm: 74.87 + 7793.58 = 7868.45
Now, since family deductible (6400) is met (6474.87 > 6400), future in-network claims will have deductible_applied = 0.
Wait, but I need to check: C's out-of-network deductible is met (6400 reached). So C's future out-of-network claims will have deductible_applied = 0.
Let me re-check the out-of-network deductible_applied calculation. The out-of-network individual deductible is 6400, and C's balance is now 6400. So C has met their out-of-network deductible.
Actually wait - the deductible_applied for out-of-network was 6400, which is exactly the threshold. So C's balance is now 6400, and the remainder is 0.
Let me reconsider: does C's deductible_applied of 6400 also count toward the family deductible? Yes, per the rules: "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
So family deductible balance is now 74.87 + 6400 = 6474.87.
But wait, for the family deductible, the threshold is 6400 (aggregate). Since 6474.87 > 6400, the family deductible is met.
Now let me also check C's OOPM. C's OOPM balance is 7793.58.
- For in-network, C's individual OOPM threshold is 7000. Since 7793.58 > 7000, C has met their in-network OOPM.
- For out-of-network, C's individual OOPM threshold is 14000. Since 7793.58 < 14000, C has NOT met their out-of-network OOPM.
Family OOPM: 7868.45. Family in-network OOPM threshold is 14000. Not met.
---
LINE 3: Claim 3 — 2026-02-01 — C (child)
Diagnostic laboratory panel, out-of-network
Allowed: 967.99
Out-of-network.
C's deductible balance = 6400. Out-of-network threshold = 6400. Remainder = 0.
Deductible_applied = 0.00
Remaining = 967.99
Coinsurance (40% member): 967.99 * 0.40 = 387.196 → 387.20
Plan coinsurance: 967.99 * 0.60 = 580.794 → 580.79
Wait, let me be more careful with rounding. The task says "Round half up to the cent at the end of a calculation."
967.99 * 0.40 = 387.196. Rounded half up to cent: 387.20.
967.99 * 0.60 = 580.794. Rounded half up to cent: 580.79.
Check: 387.20 + 580.79 = 967.99. Yes.
Member responsibility = 0 + 387.20 = 387.20
Plan paid = 580.79
C: ded = 6400, oopm = 7793.58 + 387.20 = 8180.78
Family: ded = 6474.87, oopm = 7868.45 + 387.20 = 8255.65
Wait, does deductible_applied of 0 add to the deductible balance? No, 0 adds 0.
But wait - C's OOPM for in-network is 7000. C has already passed that (7793.58). So if this were in-network, C would pay 0. But this is out-of-network, and C's out-of-network OOPM is 14000. C's balance is 8180.78, which is less than 14000. So C still pays coinsurance for out-of-network.
But wait, should I check the OOPM before applying coinsurance? 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."
So the OOPM check should limit the member responsibility. Let me think about this.
For out-of-network, C's OOPM threshold is 14000. C's current OOPM balance is 7793.58. The coinsurance amount is 387.20. 7793.58 + 387.20 = 8180.78 < 14000. So no capping needed.
---
LINE 4: Claim 4 — 2026-02-15 — A (subscriber)
Urgent care visit, in-network
Allowed: 255.34
In-network, aggregate.
Family deductible balance = 6474.87. Family threshold = 6400. Remainder = 0 (since 6474.87 > 6400).
Deductible_applied = 0.00
Remaining = 255.34
Coinsurance (in-network, 10% member): 255.34 * 0.10 = 25.534 → 25.53
Plan: 255.34 * 0.90 = 229.806 → 229.81
Check: 25.53 + 229.81 = 255.34. Yes.
Now check A's OOPM. A's OOPM balance = 74.87. Threshold for in-network = 7000.
74.87 + 25.53 = 100.40 < 7000. No capping.
Member responsibility = 25.53
Plan paid = 229.81
A: ded = 74.87, oopm = 74.87 + 25.53 = 100.40
Family: ded = 6474.87, oopm = 8255.65 + 25.53 = 8281.18
---
LINE 5: Claim 5 — 2026-03-01 — A (subscriber)
Emergency department visit, in-network
Allowed: 3545.18
In-network, aggregate.
Family deductible remainder = 0 (already met).
Deductible_applied = 0.00
Remaining = 3545.18
Coinsurance (10% member): 3545.18 * 0.10 = 354.518 → 354.52
Plan: 3545.18 * 0.90 = 3190.662 → 3190.66
Check: 354.52 + 3190.66 = 3545.18. Yes.
A's OOPM balance = 100.40. Threshold = 7000.
100.40 + 354.52 = 454.92 < 7000. No capping.
Member responsibility = 354.52
Plan paid = 3190.66
A: ded = 74.87, oopm = 100.40 + 354.52 = 454.92
Family: ded = 6474.87, oopm = 8281.18 + 354.52 = 8635.70
---
LINE 6: Claim 6 — 2026-03-07 — A (subscriber)
Allergy testing, in-network
Allowed: 911.89
In-network, aggregate.
Family deductible remainder = 0.
Deductible_applied = 0.00
Remaining = 911.89
Coinsurance (10%): 911.89 * 0.10 = 91.189 → 91.19
Plan: 911.89 * 0.90 = 820.701 → 820.70
Check: 91.19 + 820.70 = 911.89. Yes.
A's OOPM = 454.92. 454.92 + 91.19 = 546.11 < 7000.
Member responsibility = 91.19
Plan paid = 820.70
A: ded = 74.87, oopm = 454.92 + 91.19 = 546.11
Family: ded = 6474.87, oopm = 8635.70 + 91.19 = 8726.89
---
LINE 7: Claim 7 — 2026-03-19 — B (spouse)
Ambulatory surgery, in-network
Allowed: 7845.50
In-network, aggregate.
Family deductible remainder = 0.
Deductible_applied = 0.00
Remaining = 7845.50
Coinsurance (10%): 7845.50 * 0.10 = 784.55
Plan: 7845.50 * 0.90 = 7060.95
Check: 784.55 + 7060.95 = 7845.50. Yes.
B's OOPM = 0. 0 + 784.55 = 784.55 < 7000.
Member responsibility = 784.55
Plan paid = 7060.95
B: ded = 0, oopm = 784.55
Family: ded = 6474.87, oopm = 8726.89 + 784.55 = 9511.44
Wait, does B's deductible balance change? Deductible_applied is 0, so B's ded balance stays 0.
Actually, wait. Let me reconsider the deductible for B. In aggregate structure, the family deductible is 6400. B hasn't personally contributed to the deductible, but the family has met it. So B gets coinsurance on in-network. That's correct.
But what about B's own deductible balance? It stays 0. For out-of-network purposes, B's single deductible balance is 0, and the out-of-network threshold is 6400.
---
LINE 8: Claim 8 — 2026-03-28 — D (child)
Ambulatory surgery, in-network
Allowed: 6750.63
In-network, aggregate.
Family deductible remainder = 0.
Deductible_applied = 0.00
Remaining = 6750.63
Coinsurance (10%): 6750.63 * 0.10 = 675.063 → 675.06
Plan: 6750.63 * 0.90 = 6075.567 → 6075.57
Check: 675.06 + 6075.57 = 6750.63. Yes.
D's OOPM = 0. 0 + 675.06 = 675.06 < 7000.
Member responsibility = 675.06
Plan paid = 6075.57
D: ded = 0, oopm = 675.06
Family: ded = 6474.87, oopm = 9511.44 + 675.06 = 10186.50
---
LINE 9: Claim 9 — 2026-04-11 — B (spouse)
Inpatient admission, in-network
Allowed: 12250.27
In-network, aggregate.
Family deductible remainder = 0.
Deductible_applied = 0.00
Remaining = 12250.27
Coinsurance (10%): 12250.27 * 0.10 = 1225.027 → 1225.03
Plan: 12250.27 * 0.90 = 11025.243 → 11025.24
Check: 1225.03 + 11025.24 = 12250.27. Yes.
B's OOPM = 784.55. 784.55 + 1225.03 = 2009.58 < 7000.
Member responsibility = 1225.03
Plan paid = 11025.24
B: ded = 0, oopm = 2009.58
Family: ded = 6474.87, oopm = 10186.50 + 1225.03 = 11411.53
---
LINE 10: Claim 10 — 2026-04-27 — D (child)
Inpatient admission, in-network
Allowed: 12224.51
In-network, aggregate.
Family deductible remainder = 0.
Deductible_applied = 0.00
Remaining = 12224.51
Coinsurance (10%): 12224.51 * 0.10 = 1222.451 → 1222.45
Plan: 12224.51 * 0.90 = 11002.059 → 11002.06
Check: 1222.45 + 11002.06 = 12224.51. Yes.
D's OOPM = 675.06. 675.06 + 1222.45 = 1897.51 < 7000.
Member responsibility = 1222.45
Plan paid = 11002.06
D: ded = 0, oopm = 1897.51
Family: ded = 6474.87, oopm = 11411.53 + 1222.45 = 12633.98
---
LINE 11: Claim 11 — 2026-05-10 — D (child)
Annual wellness visit, out-of-network
Allowed: 664.62
Out-of-network. "Annual wellness visit" - is this preventive care?
The plan says: "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."
And from the rules: "Preventive services in-network carry no cost share and move no accumulator. An out-of-network preventive service is subject to the out-of-network deductible and coinsurance."
An annual wellness visit is a preventive service. Since it's out-of-network, it IS subject to deductible and coinsurance.
D's single deductible balance = 0.
Out-of-network threshold = 6400.
Remainder = 6400 - 0 = 6400.
Deductible_applied = min(664.62, 6400) = 664.62
All goes to deductible.
Member responsibility = 664.62
Plan paid = 0.00
D: ded = 0 + 664.62 = 664.62, oopm = 1897.51 + 664.62 = 2562.13
Family: ded = 6474.87 + 664.62 = 7139.49, oopm = 12633.98 + 664.62 = 13298.60
---
LINE 12: Claim 12 — 2026-05-17 — B (spouse)
Generic retail pharmacy fill, out-of-network
Allowed: 30.19
Out-of-network.
B's single deductible balance = 0.
Out-of-network threshold = 6400.
Remainder = 6400.
Deductible_applied = min(30.19, 6400) = 30.19
Member responsibility = 30.19
Plan paid = 0.00
B: ded = 0 + 30.19 = 30.19, oopm = 2009.58 + 30.19 = 2039.77
Family: ded = 7139.49 + 30.19 = 7169.68, oopm = 13298.60 + 30.19 = 13328.79
---
LINE 13: Claim 13 — 2026-05-24 — D (child)
Screening colonoscopy, no polyp removed, out-of-network
Allowed: 716.51
Out-of-network. Screening colonoscopy is a preventive service. Since it's out-of-network, it's subject to deductible and coinsurance.
D's single deductible balance = 664.62.
Out-of-network threshold = 6400.
Remainder = 6400 - 664.62 = 5735.38.
Deductible_applied = min(716.51, 5735.38) = 716.51
Member responsibility = 716.51
Plan paid = 0.00
D: ded = 664.62 + 716.51 = 1381.13, oopm = 2562.13 + 716.51 = 3278.64
Family: ded = 7169.68 + 716.51 = 7886.19, oopm = 13328.79 + 716.51 = 14045.30
---
LINE 14: VOID of Claim 3 — 2026-06-06 — C (child)
Claim 3 was: C, out-of-network, allowed 967.99
Original adjudication: deductible_applied = 0, coinsurance member = 387.20, plan = 580.79
Credits to remove:
- Deductible credit: 0 (so no change to deductible balances)
- Member responsibility: 387.20 (remove from C's OOPM and family OOPM)
C: ded stays 6400, oopm = 8180.78 - 387.20 = 7793.58
Family: ded stays 7886.19, oopm = 14045.30 - 387.20 = 13658.10
Wait, let me re-read the void rule: "When a line voids an earlier claim, its credits are removed in the same way and nothing replaces them."
Claim 3 had:
- deductible_applied = 0 (no deductible credit to remove)
- member_responsibility = 387.20 (remove from C's OOPM and family OOPM)
- plan_paid = 580.79 (this is plan payment, not an accumulator credit)
So:
C's OOPM: 8180.78 - 387.20 = 7793.58
Family OOPM: 14045.30 - 387.20 = 13658.10
C's deductible stays 6400 (no deductible credit was generated by Claim 3).
Family deductible stays 7886.19.
Let me double check C's OOPM. After Claim 2, C's OOPM was 7793.58. After Claim 3, it was 8180.78. Now voiding Claim 3 brings it back to 7793.58. Correct.
Family OOPM: After Claim 2, family OOPM was 7868.45. After Claim 3, it was 8255.65. Then:
- Claim 4: +25.53 → 8281.18
- Claim 5: +354.52 → 8635.70
- Claim 6: +91.19 → 8726.89
- Claim 7: +784.55 → 9511.44
- Claim 8: +675.06 → 10186.50
- Claim 9: +1225.03 → 11411.53
- Claim 10: +1222.45 → 12633.98
- Claim 11: +664.62 → 13298.60
- Claim 12: +30.19 → 13328.79
- Claim 13: +716.51 → 14045.30
Now void Claim 3 (387.20): 14045.30 - 387.20 = 13658.10. Correct.
---
LINE 15: Claim 15 — 2026-06-18 — A (subscriber)
Outpatient endoscopy, out-of-network
Allowed: 2331.25
Out-of-network.
A's single deductible balance = 74.87.
Out-of-network threshold = 6400.
Remainder = 6400 - 74.87 = 6325.13.
Deductible_applied = min(2331.25, 6325.13) = 2331.25
All goes to deductible.
Member responsibility = 2331.25
Plan paid = 0.00
A: ded = 74.87 + 2331.25 = 2406.12, oopm = 546.11 + 2331.25 = 2877.36
Family: ded = 7886.19 + 2331.25 = 10217.44, oopm = 13658.10 + 2331.25 = 15989.35
---
LINE 16: VOID of Claim 6 — 2026-06-22 — A (subscriber)
Claim 6 was: A, in-network, allowed 911.89
Original adjudication: deductible_applied = 0, coinsurance member = 91.19, plan = 820.70
Credits to remove:
- Deductible credit: 0
- Member responsibility: 91.19
A: ded stays 2406.12, oopm = 2877.36 - 91.19 = 2786.17
Family: ded stays 10217.44, oopm = 15989.35 - 91.19 = 15898.16
---
LINE 17:[empty response]Grader detail
json{
"reason": "response did not contain parseable JSON"
}Reasoning · 18,142 tokens
Let me work through this step by step. This is an AGGREGATE deductible structure, meaning the family deductible of 6400.00 must be satisfied in full before the plan pays any coinsurance for any member. There is no individual deductible under this structure.
Wait, let me re-read the plan document carefully:
"Deductible
Individual (in-network) ................ 3200.00
Family (in-network) .................... 6400.00
Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
So under aggregate, the family deductible of 6400.00 must be met before any coinsurance kicks in for any member. There is no individual deductible.
"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
in-network ......... the smaller of the member's individual remainder and
the family remainder (embedded), or the family
remainder alone (aggregate);"
So for in-network claims under aggregate, deductible_applied = lesser of allowed amount and family remainder.
For out-of-network:
"out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."
Wait, the out-of-network deductible is 6400.00 individual. And "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
But under aggregate structure, there is no individual deductible for in-network. Let me re-read...
"Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
So for in-network, the family deductible of 6400.00 must be met. There's no individual deductible threshold.
For out-of-network, the individual deductible is 6400.00.
"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 a single deductible balance per member. For in-network services under aggregate, we measure against the family remainder (6400.00 total family credits needed). For out-of-network services, we measure against the out-of-network individual remainder (6400.00 per member).
Wait, but how does the family deductible work with out-of-network claims? Let me re-read:
"Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
So out-of-network claims:
- Measured against out-of-network individual deductible (6400.00)
- Credits still go to family balance
But for in-network claims under aggregate:
- Measured against family remainder only (since no individual deductible)
- Credits go to family balance
Let me think about this more carefully. The family deductible is 6400.00 for in-network. Under aggregate, the family deductible must be met before any coinsurance.
For out-of-network, the individual deductible is 6400.00. The out-of-network claims don't count toward the in-network family deductible threshold... wait, let me re-read:
"In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
So all deductible credits (both in-network and out-of-network) go into one bucket per member. But the threshold they're measured against depends on whether the service is in-network or out-of-network.
For in-network under aggregate: the family remainder (6400.00 - family deductible credits so far).
For out-of-network: the out-of-network individual remainder (6400.00 - member's single deductible balance).
And credits from both in-network and out-of-network accumulate to the member's balance AND the family balance.
Wait, but if out-of-network credits go to the family balance, does that help satisfy the in-network family deductible? Let me re-read:
"The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
I think the family balance tracks total deductible credits from all sources. And for in-network under aggregate, we check if the family balance has reached 6400.00.
Let me re-read the accumulator rules:
"A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)."
So the family deductible balance is the running total of all deductible_applied across all family members.
Let me trace through each claim:
INITIAL STATE:
- Family deductible balance: 0.00
- Family OOPM balance: 0.00
- A: deductible balance 0.00, OOPM balance 0.00
- B: deductible balance 0.00, OOPM balance 0.00
- C: deductible balance 0.00, OOPM balance 0.00
- D: deductible balance 0.00, OOPM balance 0.00
- E: deductible balance 0.00, OOPM balance 0.00
Family deductible threshold: 6400.00 (aggregate, in-network)
Family OOPM threshold: 14000.00
Individual OOPM in-network: 7000.00
Individual OOPM out-of-network: 14000.00
Out-of-network individual deductible: 6400.00
Since it's aggregate, for in-network claims, deductible_applied = lesser of allowed amount and family remainder.
Wait, but I need to think about this. If there's no individual deductible under aggregate, then all in-network claims go 100% to the family deductible until the family deductible is met. Once the family deductible is met, coinsurance kicks in for all members.
For out-of-network claims, the individual out-of-network deductible is 6400.00. So an out-of-network claim's deductible_applied is measured against the member's out-of-network individual remainder (6400.00 - member's deductible balance).
But wait - "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." So the member's deductible balance includes both in-network and out-of-network credits.
For out-of-network, the threshold is 6400.00 (out-of-network individual deductible).
For in-network under aggregate, the threshold is the family remainder.
Let me also think about OOPM. The OOPM tracks member_responsibility.
- Individual in-network OOPM: 7000.00
- Family in-network OOPM: 14000.00
- Individual out-of-network OOPM: 14000.00
For in-network claims, member responsibility counts toward individual in-network OOPM (7000.00) and family OOPM (14000.00).
For out-of-network claims, member responsibility counts toward individual out-of-network OOPM (14000.00). Does it also count toward family OOPM?
The plan says:
"Out-of-pocket maximum
Individual (in-network) ................ 7000.00
Family (in-network) .................... 14000.00
Individual (out-of-network) ............ 14000.00"
And: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
So out-of-network member responsibility counts toward the family OOPM balance as well. The family OOPM is 14000.00.
Actually, wait. Let me re-read: "the family amounts, which are in-network amounts, do not limit an out-of-network claim."
I think for OOPM:
- In-network claims: member responsibility counts toward individual in-network OOPM (7000.00) and family OOPM (14000.00)
- Out-of-network claims: member responsibility counts toward individual out-of-network OOPM (14000.00) and family OOPM (14000.00)
Once individual OOPM is reached (in-network or out-of-network depending on the service), plan pays 100%.
Once family OOPM is reached, plan pays 100% for all members.
Actually, I need to think about this differently. 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."
So it's per-member. If a member reaches their individual OOPM, plan pays 100% for that member.
For in-network: individual OOPM is 7000.00.
For out-of-network: individual OOPM is 14000.00.
And the family OOPM is 14000.00. Once total family member responsibility reaches 14000.00, plan pays 100% for all members.
Wait, but the family OOPM says "Family (in-network) .................... 14000.00". Does out-of-network member responsibility count toward this?
I think the family OOPM of 14000.00 is the total family OOPM. Since the individual out-of-network OOPM is also 14000.00, it seems like out-of-network member responsibility would count toward the family OOPM.
Let me just track everything carefully.
Let me define:
- family_ded: total family deductible credits (threshold 6400.00 for aggregate in-network)
- member_ded[X]: individual member deductible balance (single balance for both in and out of network)
- member_oop[X]: individual member OOPM balance
- family_oop: total family OOPM balance (threshold 14000.00)
For each claim, I need to determine:
1. deductible_applied
2. coinsurance amount (after deductible is met)
3. member_responsibility = deductible_applied + coinsurance_amount
4. plan_paid = allowed - member_responsibility
Let me process each claim:
---
LINE 1: Claim 1 — 2026-01-07 — A — In-network — Allowed: 74.87
Family deductible remainder: 6400.00 - 0.00 = 6400.00
Under aggregate, in-network deductible_applied = lesser of allowed and family remainder
deductible_applied = min(74.87, 6400.00) = 74.87
Coinsurance: 0 (deductible not met)
member_responsibility = 74.87
plan_paid = 0.00
Update accumulators:
- A: ded = 0.00 + 74.87 = 74.87, oop = 0.00 + 74.87 = 74.87
- family_ded = 0.00 + 74.87 = 74.87
- family_oop = 0.00 + 74.87 = 74.87
---
LINE 2: Claim 2 — 2026-01-17 — C — Out-of-network — Allowed: 10883.95
Out-of-network. Member C's deductible balance = 0.00.
Out-of-network individual deductible = 6400.00.
C's out-of-network individual remainder = 6400.00 - 0.00 = 6400.00.
deductible_applied = min(10883.95, 6400.00) = 6400.00
After deductible, remaining allowed = 10883.95 - 6400.00 = 4483.95
Out-of-network coinsurance: 40% member / 60% plan
coinsurance_amount = 4483.95 * 0.40 = 1793.58
member_responsibility = 6400.00 + 1793.58 = 8193.58
plan_paid = 10883.95 - 8193.58 = 2690.37
Wait, I need to check OOPM. C's individual out-of-network OOPM is 14000.00.
member_responsibility = 8193.58. This is less than 14000.00, so no OOPM cap yet.
But wait, does the family OOPM apply here? Family OOPM is 14000.00.
Current family_oop = 74.87. After this claim, family_oop would be 74.87 + 8193.58 = 8268.45. Still under 14000.00.
Update accumulators:
- C: ded = 0.00 + 6400.00 = 6400.00, oop = 0.00 + 8193.58 = 8193.58
- family_ded = 74.87 + 6400.00 = 6474.87
Wait, the family deductible threshold is 6400.00 (aggregate). The family_ded is now 6474.87, which exceeds 6400.00. Does this matter?
Actually, for the family deductible under aggregate, the threshold is 6400.00. Once family_ded reaches 6400.00, the deductible is met for in-network purposes. But the family_ded balance can exceed 6400.00 because of out-of-network claims (which are measured against the out-of-network individual threshold).
Let me re-read: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
So family_ded = 6474.87. For in-network purposes, the family deductible is met (6474.87 >= 6400.00). So future in-network claims will have deductible_applied = 0.00.
- family_oop = 74.87 + 8193.58 = 8268.45
---
LINE 3: Claim 3 — 2026-02-01 — C — Out-of-network — Allowed: 967.99
C's deductible balance = 6400.00.
Out-of-network individual remainder = 6400.00 - 6400.00 = 0.00.
deductible_applied = min(967.99, 0.00) = 0.00
After deductible: remaining allowed = 967.99
Out-of-network coinsurance: 40% member
coinsurance_amount = 967.99 * 0.40 = 387.196 = 387.20
Wait, let me check OOPM. C's OOPM balance = 8193.58.
Individual out-of-network OOPM = 14000.00.
Room = 14000.00 - 8193.58 = 5806.42.
member_responsibility would be 0.00 + 387.20 = 387.20. This is less than 5806.42, so no cap.
Actually wait - I need to check family OOPM too.
Family OOPM balance = 8268.45.
Family OOPM threshold = 14000.00.
Room = 14000.00 - 8268.45 = 5731.55.
member_responsibility = 387.20 < 5731.55. No cap.
member_responsibility = 387.20
plan_paid = 967.99 - 387.20 = 580.79
Update accumulators:
- C: ded = 6400.00 (no change), oop = 8193.58 + 387.20 = 8580.78
- family_ded = 6474.87 (no change)
- family_oop = 8268.45 + 387.20 = 8655.65
---
LINE 4: Claim 4 — 2026-02-15 — A — In-network — Allowed: 255.34
Family deductible is met (family_ded = 6474.87 >= 6400.00).
So deductible_applied = 0.00.
After deductible: remaining allowed = 255.34
In-network coinsurance: 10% member
coinsurance_amount = 255.34 * 0.10 = 25.534 = 25.53
Check OOPM:
A's OOPM balance = 74.87.
Individual in-network OOPM = 7000.00.
Room = 7000.00 - 74.87 = 6925.13.
member_responsibility = 25.53 < 6925.13. OK.
Family OOPM balance = 8655.65.
Room = 14000.00 - 8655.65 = 5344.35.
member_responsibility = 25.53 < 5344.35. OK.
member_responsibility = 25.53
plan_paid = 255.34 - 25.53 = 229.81
Update accumulators:
- A: ded = 74.87 (no change), oop = 74.87 + 25.53 = 100.40
- family_oop = 8655.65 + 25.53 = 8681.18
---
LINE 5: Claim 5 — 2026-03-01 — A — In-network — Allowed: 3545.18
Family deductible met. deductible_applied = 0.00.
coinsurance_amount = 3545.18 * 0.10 = 354.518 = 354.52
Check OOPM:
A's OOPM = 100.40. Room = 7000.00 - 100.40 = 6899.60. OK.
Family OOPM = 8681.18. Room = 14000.00 - 8681.18 = 5318.82. OK.
member_responsibility = 354.52
plan_paid = 3545.18 - 354.52 = 3190.66
Update:
- A: oop = 100.40 + 354.52 = 454.92
- family_oop = 8681.18 + 354.52 = 9035.70
---
LINE 6: Claim 6 — 2026-03-07 — A — In-network — Allowed: 911.89
Family deductible met. deductible_applied = 0.00.
coinsurance_amount = 911.89 * 0.10 = 91.189 = 91.19
Check OOPM:
A's OOPM = 454.92. Room = 7000.00 - 454.92 = 6545.08. OK.
Family OOPM = 9035.70. Room = 14000.00 - 9035.70 = 4964.30. OK.
member_responsibility = 91.19
plan_paid = 911.89 - 91.19 = 820.70
Update:
- A: oop = 454.92 + 91.19 = 546.11
- family_oop = 9035.70 + 91.19 = 9126.89
---
LINE 7: Claim 7 — 2026-03-19 — B — In-network — Allowed: 7845.50
Family deductible met. deductible_applied = 0.00.
coinsurance_amount = 7845.50 * 0.10 = 784.55
Check OOPM:
B's OOPM = 0.00. Room = 7000.00. OK.
Family OOPM = 9126.89. Room = 14000.00 - 9126.89 = 4873.11. OK.
member_responsibility = 784.55
plan_paid = 7845.50 - 784.55 = 7060.95
Update:
- B: ded = 0.00, oop = 0.00 + 784.55 = 784.55
- family_oop = 9126.89 + 784.55 = 9911.44
---
LINE 8: Claim 8 — 2026-03-28 — D — In-network — Allowed: 6750.63
Family deductible met. deductible_applied = 0.00.
coinsurance_amount = 6750.63 * 0.10 = 675.063 = 675.06
Check OOPM:
D's OOPM = 0.00. Room = 7000.00. OK.
Family OOPM = 9911.44. Room = 14000.00 - 9911.44 = 4088.56. OK.
member_responsibility = 675.06
plan_paid = 6750.63 - 675.06 = 6075.57
Update:
- D: ded = 0.00, oop = 0.00 + 675.06 = 675.06
- family_oop = 9911.44 + 675.06 = 10586.50
---
LINE 9: Claim 9 — 2026-04-11 — B — In-network — Allowed: 12250.27
Family deductible met. deductible_applied = 0.00.
coinsurance_amount = 12250.27 * 0.10 = 1225.027 = 1225.03
Check OOPM:
B's OOPM = 784.55. Room = 7000.00 - 784.55 = 6215.45. OK.
Family OOPM = 10586.50. Room = 14000.00 - 10586.50 = 3413.50. OK.
member_responsibility = 1225.03
plan_paid = 12250.27 - 1225.03 = 11025.24
Update:
- B: oop = 784.55 + 1225.03 = 2009.58
- family_oop = 10586.50 + 1225.03 = 11811.53
---
LINE 10: Claim 10 — 2026-04-27 — D — In-network — Allowed: 12224.51
Family deductible met. deductible_applied = 0.00.
coinsurance_amount = 12224.51 * 0.10 = 1222.451 = 1222.45
Check OOPM:
D's OOPM = 675.06. Room = 7000.00 - 675.06 = 6324.94. OK.
Family OOPM = 11811.53. Room = 14000.00 - 11811.53 = 2188.47. OK.
member_responsibility = 1222.45
plan_paid = 12224.51 - 1222.45 = 11002.06
Update:
- D: oop = 675.06 + 1222.45 = 1897.51
- family_oop = 11811.53 + 1222.45 = 13033.98
---
LINE 11: Claim 11 — 2026-05-10 — D — Out-of-network — Allowed: 664.62
Service: Annual wellness visit, out-of-network
This is an out-of-network preventive service. The plan document says:
"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."
And from the rules: "Preventive services in-network carry no cost share and move no accumulator. An out-of-network preventive service is subject to the out-of-network deductible and coinsurance."
So this is out-of-network preventive. It IS subject to out-of-network deductible and coinsurance.
D's deductible balance = 0.00.
Out-of-network individual deductible = 6400.00.
D's out-of-network remainder = 6400.00 - 0.00 = 6400.00.
deductible_applied = min(664.62, 6400.00) = 664.62
Coinsurance: 0 (deductible not met for out-of-network)
member_responsibility = 664.62
plan_paid = 0.00
Update:
- D: ded = 0.00 + 664.62 = 664.62, oop = 1897.51 + 664.62 = 2562.13
- family_ded = 6474.87 + 664.62 = 7139.49
- family_oop = 13033.98 + 664.62 = 13698.60
---
LINE 12: Claim 12 — 2026-05-17 — B — Out-of-network — Allowed: 30.19
B's deductible balance = 0.00.
Out-of-network individual remainder = 6400.00 - 0.00 = 6400.00.
deductible_applied = min(30.19, 6400.00) = 30.19
Coinsurance: 0 (deductible not met for out-of-network)
member_responsibility = 30.19
plan_paid = 0.00
Update:
- B: ded = 0.00 + 30.19 = 30.19, oop = 2009.58 + 30.19 = 2039.77
- family_ded = 7139.49 + 30.19 = 7169.68
- family_oop = 13698.60 + 30.19 = 13728.79
---
LINE 13: Claim 13 — 2026-05-24 — D — Out-of-network — Allowed: 716.51
Service: Screening colonoscopy, no polyp removed, out-of-network
This is a preventive service (screening colonoscopy). Out-of-network preventive is subject to deductible and coinsurance.
D's deductible balance = 664.62.
Out-of-network individual remainder = 6400.00 - 664.62 = 5735.38.
deductible_applied = min(716.51, 5735.38) = 716.51
Coinsurance: 0 (deductible not met)
member_responsibility = 716.51
plan_paid = 0.00
Update:
- D: ded = 664.62 + 716.51 = 1381.13, oop = 2562.13 + 716.51 = 3278.64
- family_ded = 7169.68 + 716.51 = 7886.19
- family_oop = 13728.79 + 716.51 = 14445.30
Wait, family_oop is now 14445.30, which exceeds the family OOPM of 14000.00. But this is fine - the balance can exceed the threshold. The important thing is that once the threshold is reached, future claims are affected.
Actually, let me re-check. The family OOPM threshold is 14000.00. Once family_oop reaches 14000.00, the plan pays 100% for all members for in-network services.
But wait, does the family OOPM cap apply during this claim? Let me think...
The family_oop before this claim was 13728.79. The member_responsibility for this claim is 716.51.
13728.79 + 716.51 = 14445.30.
Since 14445.30 > 14000.00, should we cap the member_responsibility?
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."
This says "a member" - so it's individual OOPM. But there's also a family OOPM.
Actually, for embedded OOPM structures, when the family OOPM is reached, all members get 100% coverage. Let me check if this plan has embedded OOPM...
The plan document says:
"Out-of-pocket maximum
Individual (in-network) ................ 7000.00
Family (in-network) .................... 14000.00json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}67GLM-5.3 · Z.ai234.9s · 27,918 out | 191.3s · 27,360 out | 193.8s · 30,000 out
Reasoning · 20,661 tokens
Let me work through this carefully.
Plan: Trinity HDHP 3200. Aggregate deductible. Family in-network deductible 6400.00 (aggregate — no member reaches coinsurance until family credits reach 6400). Out-of-network individual deductible 6400.00, measured against the member's single deductible balance. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. Family in-network deductible threshold 6400 aggregate.
Wait — the plan says aggregate structure: "the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." And out-of-network individual deductible 6400.00, "the threshold that balance is measured against when the service is out-of-network."
The accumulators addendum says:
- in-network: the family remainder alone (aggregate)
- out-of-network: the out-of-network individual remainder, measured against the member's same single deductible balance.
So for an in-network claim, deductible_applied = min(allowed, family remainder = 6400 - family deductible balance). For an out-of-network claim, deductible_applied = min(allowed, OON individual remainder = 6400 - member's deductible balance).
Coinsurance: in-network 10% member / 90% plan; out-of-network 40% member / 60% plan.
OOPM: individual in-network 7000, family in-network 14000, individual OON 14000. Once a member reaches the OOPM, plan pays 100%.
Note: the OOPM thresholds — in-network OOPM individual 7000, family 14000; OON individual 14000. The addendum says balances are not capped at in-network amounts. Hmm, but for the OOPM, how do we measure? Similar structure presumably: in-network claims measured against... individual OOPM remainder and family OOPM remainder? The plan says "Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000". Once a member reaches the OOPM the plan pays 100% of allowed.
Let me just process the ledger line by line, tracking:
- Each member's deductible balance (single balance, both IN and OON credits).
- Each member's OOP balance (running total of member_responsibility).
- Family deductible balance (total of deductible credits).
- Family OOP balance (total of member responsibilities).
Initial: all zero.
Line 1 — Claim 1 — A — IN — allowed 74.87.
Family deductible remainder = 6400 - 0 = 6400. Deductible_applied = min(74.87, 6400) = 74.87. Member responsibility = 74.87 (all deductible). Plan paid 0.
A ded = 74.87, A OOP = 74.87. Family ded = 74.87, family OOP = 74.87.
Line 2 — Claim 2 — C — OON — allowed 10883.95.
OON individual remainder = 6400 - C's ded (0) = 6400. Deductible_applied = min(10883.95, 6400) = 6400. Then coinsurance on remainder: 10883.95 - 6400 = 4483.95 × 40% = 1793.58. Member responsibility = 6400 + 1793.58 = 8193.58. Plan paid = 4483.95 × 60% = 2690.37.
Check OOPM: C's OOP balance before = 0. Individual OON OOPM = 14000. Does the OOPM cap this claim? C's OOP would go 0 → 8193.58, which is under 14000. But also family OOPM in-network 14000 — for an OON claim, per addendum "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts... do not limit an out-of-network claim." So OON claims measured against OON individual OOPM 14000 only.
C ded = 6400, C OOP = 8193.58. Family ded = 74.87 + 6400 = 6474.87. Family OOP = 74.87 + 8193.58 = 8268.45.
Hmm wait — but the addendum about deductibles: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." So yes, deductible_applied for OON claim measured against member's OON individual threshold (6400), not family remainder. Fine.
Line 3 — Claim 3 — C — OON — allowed 967.99.
C's ded balance = 6400. OON individual remainder = 6400 - 6400 = 0. Deductible_applied = 0. Coinsurance: 967.99 × 40% = 387.196 → 387.20 (round half up at end of calculation; let me compute precisely: 967.99 × 0.4 = 387.196 → 387.20). Member resp = 387.20. Plan paid = 967.99 × 60% = 580.794 → 580.79. Check: 387.20 + 580.79 = 967.99.
OOP check: C OOP = 8193.58 + 387.20 = 8580.78 < 14000. OK.
C OOP = 8580.78. Family ded = 6474.87 + 0 = 6474.87. Family OOP = 8268.45 + 387.20 = 8655.65.
Line 4 — Claim 4 — A — IN — allowed 255.34.
Family remainder for IN aggregate = 6400 - 6474.87 = negative → 0 (family deductible already exceeded: family ded balance 6474.87 > 6400). Deductible_applied = 0. Coinsurance 10%: 255.34 × 0.10 = 25.534 → 25.53. Member resp = 25.53. Plan paid = 255.34 × 0.90 = 229.806 → 229.81. Check: 25.53 + 229.81 = 255.34.
OOP: A = 74.87 + 25.53 = 100.40. Family OOP = 8655.65 + 25.53 = 8681.18.
Wait — is the family deductible satisfied? Under aggregate, the family threshold is 6400 and family credits total 6474.87 (including C's OON credits). Hmm, the addendum says OON credits accumulate to the family balance. And the IN claims are measured against "the family remainder alone (aggregate)". Family remainder = 6400 - family balance. Family balance = 6474.87 > 6400, so remainder 0. So yes, family deductible met (the OON credits count toward the family balance, so they count toward meeting the aggregate family deductible).
Line 5 — Claim 5 — A — IN — allowed 3545.18.
Family remainder 0 → deductible_applied 0. Coinsurance 10% = 354.518 → 354.52. Plan 90% = 3190.662 → 3190.66. Check: 354.52 + 3190.66 = 3545.18.
A OOP = 100.40 + 354.52 = 454.92. Family OOP = 8681.18 + 354.52 = 9035.70.
Line 6 — Claim 6 — A — IN — allowed 911.89.
Ded applied 0. Coinsurance 10% = 91.189 → 91.19. Plan = 820.70 (911.89 × 0.9 = 820.701 → 820.70). Check: 91.19 + 820.70 = 911.89.
A OOP = 454.92 + 91.19 = 546.11. Family OOP = 9035.70 + 91.19 = 9126.89.
Line 7 — Claim 7 — B — IN — allowed 7845.50.
Ded applied 0 (family met). Coinsurance 10% = 784.55. Plan = 7060.95. Check: 784.55 + 7060.95 = 7845.50.
B OOP = 784.55. Family OOP = 9126.89 + 784.55 = 9911.44.
Line 8 — Claim 8 — D — IN — allowed 6750.63.
Coinsurance 10% = 675.063 → 675.06. Plan = 6075.567 → 6075.57. Check: 675.06 + 6075.57 = 6750.63.
D OOP = 675.06. Family OOP = 9911.44 + 675.06 = 10586.50.
Line 9 — Claim 9 — B — IN — allowed 12250.27.
Coinsurance 10% = 1225.027 → 1225.03. Plan = 11025.243 → 11025.24. Check: 1225.03 + 11025.24 = 12250.27.
B OOP = 784.55 + 1225.03 = 2009.58. Family OOP = 10586.50 + 1225.03 = 11811.53.
Line 10 — Claim 10 — D — IN — allowed 12224.51.
Coinsurance 10% = 1222.451 → 1222.45. Plan = 11002.059 → 11002.06. Check: 1222.45 + 11002.06 = 12224.51.
D OOP = 675.06 + 1222.45 = 1897.51. Family OOP = 11811.53 + 1222.45 = 13033.98.
Line 11 — Claim 11 — D — OON — allowed 664.62. Annual wellness visit, out-of-network. Per plan: "An out-of-network preventive service is subject to the out-of-network deductible and coinsurance." So not free.
D's ded balance = 0. OON individual remainder = 6400 - 0 = 6400. Deductible_applied = 664.62. Member resp = 664.62. Plan 0.
D ded = 664.62. D OOP = 1897.51 + 664.62 = 2562.13. Family ded = 6474.87 + 664.62 = 7139.49. Family OOP = 13033.98 + 664.62 = 13698.60.
Hmm wait — D's OON deductible is measured against D's single deductible balance which includes IN credits? D's IN credits so far were all coinsurance (deductible_applied = 0) since family was met. So D's ded balance = 0 before this. Yes, 664.62 applied.
OOPM check for OON claim: D's OOP measured against OON individual OOPM 14000: 2562.13 < 14000, fine.
Line 12 — Claim 12 — B — OON — allowed 30.19.
B ded balance = 0 (B only had coinsurance claims). OON remainder = 6400. Deductible_applied = 30.19. Member resp = 30.19. Plan 0.
B ded = 30.19. B OOP = 2009.58 + 30.19 = 2039.77. Family ded = 7139.49 + 30.19 = 7169.68. Family OOP = 13698.60 + 30.19 = 13728.79.
Line 13 — Claim 13 — D — OON — allowed 716.51. Screening colonoscopy, no polyp — preventive, but OON → subject to OON deductible and coinsurance.
D ded balance = 664.62. OON remainder = 6400 - 664.62 = 5735.38. Deductible_applied = min(716.51, 5735.38) = 716.51. Member resp = 716.51. Plan 0.
D ded = 664.62 + 716.51 = 1381.13. D OOP = 2562.13 + 716.51 = 3278.64. Family ded = 7169.68 + 716.51 = 7886.19. Family OOP = 13728.79 + 716.51 = 14445.30.
Hmm, family OOP now 14445.30 — exceeds the family in-network OOPM of 14000. Does that matter? The family OOPM is an in-network amount; per the addendum, balances are not capped at the in-network amounts, and OON claims are measured against OON individual thresholds only, family amounts don't limit OON claims. But subsequent IN claims should be measured against the family OOPM remainder (in-network OOPM 14000, family). Family OOP balance 14445.30 > 14000 → family OOPM met? Under an aggregate-ish reading, once family OOP balance ≥ family OOPM, in-network claims for any member are paid 100%?
Hmm, this needs care. The plan says: "Out-of-pocket maximum: Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000. 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 phrasing "Once a member reaches the out-of-pocket maximum" — the OOPM for a member is the individual OOPM. But family OOPM 14000 means the family's combined cost share caps at 14000 for in-network. Typically in HDHPs, the family OOPM is aggregate: once family accumulations reach family OOPM, no family member pays cost share for in-network services.
The addendum on accumulators speaks about deductibles primarily ("A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)"). And "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This says balances are not capped — i.e., we keep counting. "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim."
So for an in-network claim, what limits it? The member's individual OOPM (7000 in-network individual remainder) and the family OOPM (14000 family remainder)? Presumably analogous to the deductible: an in-network claim's member responsibility is capped so that... hmm, actually the OOPM cap works differently: once a member reaches the OOPM, plan pays 100%. So the question is at each claim whether the member has reached their applicable OOPM.
Let me think about how to apply: For an in-network claim, member responsibility is the normal cost share (deductible + 10% coinsurance), unless the member has reached the individual in-network OOPM (7000) or the family has reached the family in-network OOPM (14000), in which case plan pays 100%.
For an OON claim, member responsibility is deductible + 40% coinsurance, unless member has reached the OON individual OOPM (14000)... and maybe also if family OOPM reached? The addendum says family amounts don't limit OON claims. So OON claims: only the member's OON individual OOPM (14000) limits.
Now, after Line 13, family OOP = 14445.30 ≥ 14000. So from Line 15 onward (next IN claims), the family OOPM is met, and in-network claims should be paid at 100%? Hmm, but wait — is the family OOPM truly aggregate in that sense? The plan document lists "Family (in-network) 14000". Under the standard HDHP embedded/aggregate structure... The deductible is explicitly AGGREGATE. The OOPM isn't stated as aggregate or embedded. Hmm.
But the addendum says: "the family balances past the family amounts; the balances are not capped at the in-network amounts" — this is about OON claims pushing family balances past family in-network amounts. It implies the family in-network OOPM is a real threshold of 14000.
I think the intended mechanics: for an in-network claim, if the member's OOP balance ≥ 7000 (individual in-network OOPM) OR the family OOP balance ≥ 14000 (family in-network OOPM), the plan pays 100%. Actually, more precisely, the cost share is capped so that the member doesn't pay beyond the threshold — i.e., member responsibility = min(normal cost share, remaining room under applicable OOPM). Hmm, but typical adjudication: once the OOPM is reached, plan pays 100%; the claim that crosses the threshold — the member pays only up to the threshold. Let me consider: "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 suggests that when the member's balance reaches the OOPM, subsequent services are 100%. For the crossing claim itself, the standard approach: member pays the portion that brings them to the OOPM, plan pays the rest.
The addendum for deductibles explicitly defines deductible_applied as the lesser of allowed and room left — i.e., the crossing claim is split. For OOPM, the analogous approach would cap member_responsibility at the room left under the OOPM.
Let me now check the ledger to see whether OOPM thresholds actually get hit in a way that matters.
Family OOP after line 13: 14445.30. That's above 14000. But this was driven by OON claims. Lines 15, 17, 18 are OON. Line 19 is IN (B). Lines 21, 22 IN, 24, 25 IN.
So the family in-network OOPM question matters for claims 19, 21, 22, 24, 25.
Hmm, wait. Let me reconsider. Does the family OOPM apply here? The addendum says OON claims don't get limited by family amounts, but their credits accumulate to the family balance. So the family balance includes OON credits. When an IN claim comes, is it limited by the family in-network OOPM remainder = 14000 - family balance? If family balance (14445.30) ≥ 14000, then family OOPM met → IN claims paid 100%.
Alternatively, one could argue the family OOPM only counts in-network accumulations. But the addendum says "the family balances past the family amounts; the balances are not capped at the in-network amounts" — meaning the family balance can exceed 14000 (not capped), and OON credits do accumulate to the family balance. It doesn't say OON credits are excluded from the family balance for OOPM-threshold purposes. Actually it says "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." So the family OOP balance includes everything.
So for in-network claims after the family balance reaches 14000, the family OOPM is met and plan pays 100%.
Hold on, let me recompute the family OOP at each line to be careful, and also track when 14000 is crossed.
After line 1: 74.87
Line 2: +8193.58 → 8268.45
Line 3: +387.20 → 8655.65
Line 4: +25.53 → 8681.18
Line 5: +354.52 → 9035.70
Line 6: +91.19 → 9126.89
Line 7: +784.55 → 9911.44
Line 8: +675.06 → 10586.50
Line 9: +1225.03 → 11811.53
Line 10: +1222.45 → 13033.98
Line 11: +664.62 → 13698.60
Line 12: +30.19 → 13728.79
Line 13: +716.51 → 14445.30 ← crosses 14000 during line 13 (an OON claim for D).
Line 13 is OON, so family amount doesn't limit it. D's OON individual OOPM is 14000; D's OOP was 2562.13 + 716.51 = 3278.64, well under.
After line 13, family OOP balance = 14445.30 ≥ 14000 (family in-network OOPM). So subsequent IN claims: family OOPM met → plan pays 100%? That's the question.
Hmm, but wait. Let me reconsider whether the family OOPM being "met" by OON accumulations should trigger 100% payment for IN services. The addendum says the family amounts "are in-network amounts" and "do not limit an out-of-network claim". It doesn't say anything about whether OON credits count toward meeting the family in-network OOPM for subsequent IN claims. But the credits "still accumulate to the member's balance and to the family balance" — the balance is what's measured against thresholds. For deductibles, the same logic applied: OON deductible credits accumulated to the family balance, and after C's 6400 OON credit, the family deductible (6400) was met, so IN claims for A had deductible_applied = 0 (lines 4-6). That's exactly what I did at line 4. That interpretation seems consistent: OON credits count toward the family thresholds.
Actually wait, let me double check the family deductible at line 4: family ded balance = 6474.87 which includes A's 74.87 (IN) and C's 6400 (OON). Family in-network deductible is 6400 aggregate. 6474.87 ≥ 6400 → met. So A's IN claims at lines 4-6 had zero deductible applied, only 10% coinsurance. That seems right per the addendum: "the family remainder alone (aggregate)" — family remainder = 6400 - family balance = negative → 0. Yes.
OK so similarly for OOPM: family in-network OOPM 14000; family balance (all credits) 14445.30 after line 13 → met. So IN claims from line 15 onward... but lines 15, 17, 18 are OON. Line 19 is the first IN claim after 14000 is crossed.
Hmm, hold on. But wait — should the crossing happen at line 13? Family OOP after line 12 was 13728.79, room = 271.21. Line 13 is OON so family doesn't limit it. Fine.
But actually, I should double-check whether individual OOPM matters for any member. Individual in-network OOPM 7000: A's OOP is 546.11 (after line 6), B 2039.77, C 8580.78 (after line 3; C's OOP is driven by OON claims — C's individual OON OOPM is 14000, so C is fine), D 3278.64, E 0.
C's OOP balance 8580.78 exceeds the in-network individual OOPM 7000, but those were OON claims measured against the OON individual OOPM 14000. If C later had an IN claim (line 21 — emergency department, in-network), would C's individual in-network OOPM (7000) be "met" by OON accumulations? Hmm. The addendum: "out-of-network claims can carry a member's balance past the in-network individual amount... the balances are not capped at the in-network amounts." This suggests the member's single OOP balance includes OON credits, and it can exceed 7000. When an IN claim comes, the member's balance (8580.78 + subsequent) ≥ 7000 → individual in-network OOPM met → plan pays 100% for IN claims.
Hmm, but also the family OOPM (14000) would be met by then anyway, which would also give 100%. So either way, line 21 for C: plan pays 100%.
Wait, actually, I need to be careful about line 18: C, OON, allowed 593.21. C's ded balance = 6400 (from line 2), OON remainder 0, so deductible 0, coinsurance 40% = 237.284 → 237.28. Member resp = 237.28. C OOP check: 8580.78 + 237.28 = 8818.06 < 14000 (OON individual OOPM). Plan pays 593.21 - 237.28 = 355.93 (60% = 355.926 → 355.93). OK.
But wait — before line 18, there's line 14: VOID of Claim 3. Let me handle that.
Line 14 — VOID of Claim 3 (C, OON, allowed 967.99, member resp 387.20, ded applied 0, plan 580.79). Remove credits: C's OOP -= 387.20; family OOP -= 387.20. Deductible credit was 0, so no deductible change. C's ded stays 6400. C OOP: 8580.78 - 387.20 = 8193.58. Family OOP: 14445.30 - 387.20 = 14058.10.
Claim 3 becomes: all components 0.00 (voided).
Line 15 — Claim 15 — A — OON — allowed 2331.25. Outpatient endoscopy OON.
A's ded balance = 74.87 (from line 1). OON individual remainder = 6400 - 74.87 = 6325.13. Deductible_applied = min(2331.25, 6325.13) = 2331.25. Member resp = 2331.25. Plan 0.
A ded = 74.87 + 2331.25 = 2406.12. A OOP = 546.11 + 2331.25 = 3777.36. Family ded = 7886.19 + 2331.25 = 10217.44. Family OOP = 14058.10 + 2331.25 = 16389.35.
OOPM check for A (OON): individual OON OOPM 14000; A's OOP 3777.36 < 14000. Family doesn't limit OON. OK.
Line 16 — VOID of Claim 6 (A, IN, allowed 911.89, member resp 91.19 coinsurance, ded 0, plan 820.70). Remove: A OOP -= 91.19 → 3777.36 - 91.19 = 3686.17. Family OOP -= 91.19 → 16389.35 - 91.19 = 16298.16. Deductible credit 0, no change. Claim 6 voided: all components 0.
Line 17 — Claim 17 — E — OON — allowed 1373.69. PT course OON.
E's ded = 0. OON remainder = 64json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 22,774 tokens
Let me carefully work through this ledger.
Plan: Trinity HDHP 3200.
- Individual in-network deductible: 3200.00
- Family in-network deductible: 6400.00
- Structure: AGGREGATE — plan pays no coinsurance for any member until total family credits reach the family deductible amount (6400). No individual deductible.
- Out-of-network individual deductible: 6400.00.
- In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The 6400 amount is the threshold that balance is measured against when the service is out-of-network.
- OOPM: individual in-network 7000, family in-network 14000, individual out-of-network 14000.
- Coinsurance after deductible: in-network 10% member / 90% plan; out-of-network 40% member / 60% plan.
- No copays.
- Preventive care: in-network preventive services paid at 100% allowed, no cost share, no accumulator movement. Out-of-network preventive service is subject to out-of-network deductible and coinsurance.
Accumulators addendum:
- deductible_applied = lesser of allowed amount and room left under the deductible threshold that applies:
- in-network: family remainder alone (aggregate)
- out-of-network: the out-of-network individual remainder, measured against the member's same single deductible balance.
- Once applicable threshold is met, deductible_applied is 0.
- Deductible balance = running total of deductible_applied. OOP balance = running total of member_responsibility.
- Balances not capped at in-network amounts; out-of-network thresholds are higher so balances can pass in-network amounts.
- Out-of-network claims measured against out-of-network individual thresholds only; family amounts (in-network) do not limit an out-of-network claim. Credits from OON claims still accumulate to member balance and family balance.
Hmm, this is tricky. Let me parse carefully.
Each member has a single deductible balance (credits from both IN and OON accumulate to it). For an in-network claim, the applicable threshold is the family aggregate: deductible_applied = min(allowed, family remainder = 6400 - family deductible balance). For an out-of-network claim, deductible_applied = min(allowed, OON individual remainder = 6400 - member's own deductible balance).
Wait — but the member's balance includes their own credits. The OON threshold is measured against the member's same single deductible balance. So for a member with balance X (from any claims), an OON claim applies min(allowed, 6400 - X) to deductible.
For in-network claims under aggregate: min(allowed, 6400 - family_total_deductible).
Coinsurance: after deductible applied, the remainder of allowed is subject to coinsurance at 10% (IN) or 40% (OON). But wait — under aggregate structure, "the plan pays no coinsurance for any member until total family credits reach the family deductible amount." Hmm, but the deductible_applied for an in-network claim is limited by the family remainder. So if family remainder is positive, the claim's allowed amount goes to deductible up to the remainder; any excess over the remainder would be coinsurance. Let me think.
Actually the mechanics: deductible_applied = min(allowed, room left). The rest of allowed (allowed - deductible_applied) is coinsurance at the applicable rate. For in-network, room = family remainder (aggregate). For OON, room = member's OON individual remainder.
But there's a subtlety: under aggregate, if a member's OON claims have pushed the family deductible balance to 6400+, then an in-network claim has deductible_applied = 0 (family remainder 0) and coinsurance applies. Also, if a member's own balance exceeds 6400 due to OON credits... wait, OON threshold is 6400 individual; once member's own balance ≥ 6400, OON deductible_applied = 0 and OON coinsurance applies.
Also note: in-network claims — does the member's own balance matter? Under aggregate, only family remainder matters for in-network. Hmm, but there's a weird interplay: suppose member A has balance 5000 from OON claims (all credited to family too). Family balance = 5000 (say only A has claims). An in-network claim for A: family remainder = 6400 - 5000 = 1400. So deductible_applied = min(allowed, 1400). Even though A's own balance (5000) exceeds the in-network individual threshold (3200)? Under aggregate there's no individual deductible, so yes, family remainder governs.
But wait — for OON, the threshold is member's OON individual remainder = 6400 - member's balance. And credits go to member's balance AND family balance.
Hmm, but there's a subtle issue: if family deductible is already met (≥6400) but a member's own balance is < 6400, an OON claim for that member still applies deductible up to min(allowed, 6400 - member balance). Because OON is measured against the individual OON threshold only. Interesting. And conversely, if a member's own balance ≥ 6400 but family < 6400 (possible if... hmm, family ≥ member always, since member credits count toward family. Actually family total = sum of member totals, so family ≥ any member. So member ≥ 6400 implies family ≥ 6400).
Wait, can family remainder be positive while a member's OON remainder is 0? Member balance = 6400+ implies family ≥ 6400, so family remainder = 0. OK.
Also OOPM: individual in-network 7000, family in-network 14000, individual OON 14000. Once a member reaches the OOPM the plan pays 100% of allowed. Hmm, how does OOPM interact? The accumulators addendum says OOP balance = running total of member_responsibility. The plan says once a member reaches the OOPM, the plan pays 100%. Which OOPM applies — in-network 7000 or OON 14000? Presumably the applicable threshold based on the claim's network: in-network claims measured against in-network individual OOPM (7000) and family OOPM (14000)? The addendum says "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." That's stated in the deductible accumulator section but presumably applies analogously to OOPM.
So for an in-network claim: member responsibility is capped by remaining room under individual OOPM (7000 - member OOP balance) and family OOPM (14000 - family OOP balance)? Hmm, 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 distinguish family OOPM explicitly but family OOPM exists (14000). Typically family OOPM: once family OOPM reached, plan pays 100% for all members.
Hmm, this is getting complicated. Let me just carefully compute and see whether OOPM ever binds in this ledger. The OOP balances will be large because of big claims. Let's see.
Let me set up:
Thresholds:
- IN deductible: family aggregate 6400 (no individual).
- OON deductible: individual 6400 (member's single balance measured against 6400).
- Coinsurance: IN 10% member; OON 40% member.
- OOPM: IN individual 7000; IN family 14000; OON individual 14000.
Now process lines 1–25 in order. Track for each member: ded balance, OOP balance. Family: ded balance, OOP balance.
Start: all 0.
Line 1 — Claim 1 — A — IN pharmacy — allowed 74.87.
Family ded remainder = 6400 - 0 = 6400. Deductible_applied = min(74.87, 6400) = 74.87. Coinsurance amount = 0 (rest = 0). Member resp = 74.87. Plan paid = 0.
A: ded 74.87, OOP 74.87. Family: ded 74.87, OOP 74.87.
Line 2 — Claim 2 — C — OON inpatient — allowed 10883.95.
OON individual remainder for C = 6400 - 0 = 6400. Deductible_applied = min(10883.95, 6400) = 6400.00. Remainder = 10883.95 - 6400 = 4483.95. Coinsurance 40% = 1793.58. Member resp = 6400 + 1793.58 = 8193.58.
But OOPM: OON individual OOPM = 14000. C's OOP balance 0, room = 14000. Member resp 8193.58 < 14000, OK. Family OOP: does family OOPM limit OON claim? "the family amounts, which are in-network amounts, do not limit an out-of-network claim." So no family cap for OON. Family OOP balance becomes 74.87 + 8193.58 = 8268.45. Fine, under 14000 anyway.
C: ded 6400, OOP 8193.58. Family ded: 74.87 + 6400 = 6474.87. Family OOP: 8268.45.
Plan paid for claim 2 = 60% of 4483.95 = 2690.37. Member resp + plan paid = 8193.58 + 2690.37 = 10883.95. ✓.
Line 3 — Claim 3 — C — OON lab — allowed 967.99.
C's ded balance = 6400. OON individual remainder = 6400 - 6400 = 0. Deductible_applied = 0. Coinsurance 40% of 967.99 = 387.196 → 387.20 (round half up at end; let me keep precise: 387.196). Member resp = 387.20 (rounded). Actually, let me be careful about rounding: "Round half up to the cent at the end of a calculation, not at each intermediate step." For each claim's components, we compute and round at the end. 967.99 × 0.40 = 387.196 → 387.20. Plan paid = 967.99 - 387.20 = 580.79. Or 967.99 × 0.60 = 580.794 → 580.79. Member resp + plan paid = 967.99. ✓
C: ded stays 6400 (deductible_applied 0). OOP: 8193.58 + 387.20 = 8580.78. Family ded: 6474.87 + 0 = 6474.87. Family OOP: 8268.45 + 387.20 = 8655.65.
Line 4 — Claim 4 — A — IN urgent care — allowed 255.34.
Family ded remainder = 6400 - 6474.87 = negative → 0 (family already met: 6474.87 ≥ 6400). Deductible_applied = 0. Coinsurance 10% of 255.34 = 25.534 → 25.53. Member resp = 25.53. Plan paid = 229.81 (255.34 - 25.53 = 229.81; or 90% = 229.806 → 229.81). ✓
A: ded 74.87, OOP 74.87 + 25.53 = 100.40. Family ded 6474.87, family OOP 8655.65 + 25.53 = 8681.18.
Line 5 — Claim 5 — A — IN ED visit — allowed 3545.18.
Family remainder 0 → ded applied 0. Coinsurance 10% = 354.518 → 354.52. Member resp 354.52. Plan paid 3545.18 - 354.52 = 3190.66 (90% = 3190.662 → 3190.66). ✓
A: OOP 100.40 + 354.52 = 454.92. Family OOP: 8681.18 + 354.52 = 9035.70.
Line 6 — Claim 6 — A — IN allergy testing — allowed 911.89.
Ded applied 0. Coinsurance 10% = 91.189 → 91.19. Member resp 91.19. Plan 820.70 (911.89 - 91.19 = 820.70). ✓
A: OOP 454.92 + 91.19 = 546.11. Family OOP: 9035.70 + 91.19 = 9126.89.
Line 7 — Claim 7 — B — IN ambulatory surgery — allowed 7845.50.
Family remainder 0 → ded 0. Coinsurance 10% = 784.55. Member resp 784.55. Plan 7060.95.
B: ded 0, OOP 784.55. Family OOP: 9126.89 + 784.55 = 9911.44.
Line 8 — Claim 8 — D — IN ambulatory surgery — allowed 6750.63.
Ded 0. Coinsurance 10% = 675.063 → 675.06. Member resp 675.06. Plan 6075.57 (6750.63 - 675.06 = 6075.57). ✓
D: ded 0, OOP 675.06. Family OOP: 9911.44 + 675.06 = 10586.50.
Line 9 — Claim 9 — B — IN inpatient — allowed 12250.27.
Ded 0. Coinsurance 10% = 1225.027 → 1225.03. Member resp 1225.03.
Check OOPM for B: B's OOP balance 784.55, room to 7000 = 6215.45. Member resp 1225.03 < room. OK. Family OOP: 10586.50 + 1225.03 = 11811.53 < 14000. OK.
Plan paid: 12250.27 - 1225.03 = 11025.24.
B: OOP 784.55 + 1225.03 = 2009.58. Family OOP 11811.53.
Line 10 — Claim 10 — D — IN inpatient — allowed 12224.51.
Ded 0. Coinsurance 10% = 1222.451 → 1222.45. Member resp 1222.45.
OOPM check D: 675.06 + 1222.45 = 1897.51 < 7000. Family OOP: 11811.53 + 1222.45 = 13033.98 < 14000. OK.
Plan paid: 12224.51 - 1222.45 = 11002.06.
D: OOP 1897.51. Family OOP 13033.98.
Line 11 — Claim 11 — D — OON annual wellness visit — allowed 664.62.
Preventive but OON → subject to OON deductible and coinsurance.
D's ded balance = 0. OON individual remainder = 6400 - 0 = 6400. Deductible_applied = min(664.62, 6400) = 664.62. Coinsurance 0. Member resp = 664.62. Plan paid 0.
OOPM check: D OOP 1897.51 + 664.62 = 2562.13 < 14000 OON individual. OK.
D: ded 664.62, OOP 2562.13. Family ded: 6474.87 + 664.62 = 7139.49. Family OOP: 13033.98 + 664.62 = 13698.60.
Line 12 — Claim 12 — B — OON pharmacy — allowed 30.19.
B's ded balance = 0. OON remainder = 6400. Deductible_applied = 30.19. Member resp 30.19. Plan 0.
B: ded 30.19, OOP 2009.58 + 30.19 = 2039.77. Family ded: 7139.49 + 30.19 = 7169.68. Family OOP: 13698.60 + 30.19 = 13728.79.
Line 13 — Claim 13 — D — OON screening colonoscopy (preventive, OON) — allowed 716.51.
D's ded balance = 664.62. OON remainder = 6400 - 664.62 = 5735.38. Deductible_applied = min(716.51, 5735.38) = 716.51. Member resp 716.51. Plan 0.
D: ded 664.62 + 716.51 = 1381.13. OOP 2562.13 + 716.51 = 3278.64. Family ded: 7169.68 + 716.51 = 7886.19. Family OOP: 13728.79 + 716.51 = 14445.30.
Family OOP is now 14445.30, above family in-network OOPM 14000. But does family OOPM affect OON claims? "the family amounts, which are in-network amounts, do not limit an out-of-network claim." So no. And future IN claims — family OOPM 14000 has been exceeded... but "Once a member reaches the out-of-pocket maximum the plan pays 100%..." Hmm, the family OOPM: once family OOPM reached, plan pays 100% for all members? The plan document lists family OOPM of 14000. Standard interpretation: once family OOP accumulations reach 14000, plan pays 100% for everyone. But the addendum says family amounts don't limit OON claims. Let me keep this in mind for later lines.
Actually wait — let me reconsider. The addendum statement about family amounts is in the ACCUMULATORS section and mentions "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." This is in the context of deductibles primarily ("measured against the out-of-network individual thresholds"), but the OOPM thresholds are also network-specific: individual OON 14000. The family OOPM 14000 is an in-network amount. So for OON claims, only the OON individual OOPM (14000) limits. For IN claims, the individual IN OOPM (7000) and family IN OOPM (14000) limit.
Line 14 — VOID of Claim 3 — C.
Remove Claim 3's credits: C's ded credited 0.00 (claim 3 had deductible_applied 0), member resp 387.20 removed from C's OOP and family OOP.
C: OOP 8580.78 - 387.20 = 8193.58. Family OOP: 14445.30 - 387.20 = 14058.10.
Claim 3 now has all components 0.00 (voided).
Family OOP = 14058.10. Family ded unchanged (claim 3 credited 0): 7886.19.
Line 15 — Claim 15 — A — OON outpatient endoscopy — allowed 2331.25.
A's ded balance = 74.87. OON individual remainder = 6400 - 74.87 = 6325.13. Deductible_applied = min(2331.25, 6325.13) = 2331.25. Member resp 2331.25. Plan 0.
OOPM check (OON individual 14000): A OOP 546.11 + 2331.25 = 2877.36 < 14000. OK.
A: ded 74.87 + 2331.25 = 2406.12. OOP 2877.36. Family ded: 7886.19 + 2331.25 = 10217.44. Family OOP: 14058.10 + 2331.25 = 16389.35.
Line 16 — VOID of Claim 6 — A.
Remove Claim 6's credits: deductible_applied 0, member resp 91.19 from A OOP and family OOP.
A: OOP 2877.36 - 91.19 = 2786.17. Family OOP: 16389.35 - 91.19 = 16298.16.
Claim 6 components all 0.00.
Line 17 — Claim 17 — E — OON physical therapy — allowed 1373.69.
E's ded balance = 0. OON remainder = 6400. Deductible_applied = 1373.69. Member resp 1373.69. Plan 0.
E: ded 1373.69, OOP 1373.69. Family ded: 10217.44 + 1373.69 = 11591.13. Family OOP: 16298.16 + 1373.69 = 17671.85.
Line 18 — Claim 18 — C — OON lab — allowed 593.21.
C's ded balance = 6400. OON remainder = 0. Deductible_applied 0. Coinsurance 40% = 237.284 → 237.28. Member resp 237.28. Plan 593.21 - 237.28 = 355.93.
OOPM check: C's OOP 8193.58 + 237.28 = 8430.86 < 14000 (OON individual). OK.
C: ded 6400, OOP 8430.86. Family ded 11591.13 (no change). Family OOP: 17671.85 + 237.28 = 17909.13.
Line 19 — Claim 19 — B — IN urgent care — allowed 220.46.
IN claim: family ded remainder = 6400 - 11591.13 → 0 (already met). Deductible_applied 0. Coinsurance 10% = 22.046 → 22.05. Member resp 22.05.
OOPM check for IN claim: B's individual IN OOPM 7000: B OOP 2039.77 + 22.05 = 2061.82 < 7000. Family IN OOPM 14000: family OOP is 17909.13, which exceeds 14000! Hmm. Does that mean the plan pays 100% for B's in-network claim because the family OOPM is reached?
This is a critical decision point. The plan document says: "Out-of-pocket maximum: Individual (in-network) 7000, Family (in-network) 14000, Individual (out-of-network) 14000. 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."
"Once a member reaches the out-of-pocket maximum" — that's about a member reaching it. The family OOPM is 14000; when the family accumulations reach 14000, the family OOPM is reached, and then... standard ACA-style: expenses for any member are covered 100% once family OOPM is reached. But the plan's wording says "once a member reaches" — hmm.
But look at the addendum: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." And: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
Hmm — "the balances are not capped at the in-network amounts". This says balances can exceed the in-network amounts (7000 individual / 14000 family). It says the BALANCES aren't capped. But does exceeding the in-network threshold via OON credits trigger 100% payment for in-network claims? That's the question.
Hmm. Let's think about how the harness intends this. The addendum describes: deductible balance is running total of deductible_applied; OOP balance is running total of member_responsibility. "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
I think the intent: the in-network thresholds apply as limits (caps on cost share) for in-network claims; the OON thresholds for OON claims. A member's OOP balance exceeding 7000 due to OON claims doesn't mean in-network claims are free — because the member hasn't reached their in-network OOPM? Hmm, but that seems weird too. Actually wait — in real HDHP/ACA plans, there's a single OOPM that applies; in-network and out-of-network OOPMs are separate, and OON expenses typically don't count toward the in-network OOPM... Actually in real plans, there are usually two separate OOPMs and expenses count toward the corresponding one. Here, the plan has a single deductible balance but the OOPM... The addendum says "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." — singular balance. So there's one OOP balance per member that accumulates all member responsibility. The thresholds that this balance is measured against depend on the network of the claim being adjudicated: in-network claims measured against 7000 individual / 14000 family; OON claims measured against 14000 individual (family doesn't limit).
So the question: when adjudicating an in-network claim, if the member's OOP balance (which includes OON credits) is ≥ 7000, is the claim paid 100%? The addendum says the balances "are not capped at the in-network amounts" — meaning the balance itself keeps growing. But does an in-network claim get free if balance ≥ 7000?
Hmm. I think the natural reading of the harness design: yes — the OOPM works as a threshold: once the applicable threshold is reached (measured against the same single balance), the claim is paid 100%. The addendum's point is that the balance isn't capped — it keeps accumulating past the in-network amounts due to OON claims — but for adjudicating an in-network claim, you measure the member's balance against the in-network threshold. If the balance ≥ 7000, in-network claims are 100% covered. Similarly, if family balance ≥ 14000, in-network claims are 100% for all members? Hmm, but the family OOPM semantics...
Wait, actually let me reconsider. Let me re-read: "Once a member reaches the out-of-pocket maximum the plan pays 100% of json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 25,251 tokens
Let me work through this ledger carefully.
Plan: Trinity HDHP 3200, plan year 2026.
- Deductible: Individual in-network 3200.00, Family in-network 6400.00, AGGREGATE structure — the plan pays no coinsurance for any member until total family credits reach the family deductible amount (6400.00). No individual deductible.
- OON individual deductible: 6400.00. 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 6400.00.
- OOPM: Individual in-network 7000.00, Family in-network 14000.00, OON individual 14000.00. Once a member reaches OOPM, plan pays 100% of allowed for covered services for remainder of plan year.
- Coinsurance after deductible: in-network 10% member / 90% plan; OON 40% member / 60% plan.
- No copays.
- Preventive care in-network: 100% allowed, no cost share, no accumulator movement. OON preventive: subject to OON deductible and coinsurance.
- Member cost share calculated from allowed amount.
Accumulators addendum:
- A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies:
- in-network: family remainder alone (aggregate) — so room = 6400.00 − family deductible balance.
- OON: the OON individual remainder, measured against the member's same single deductible balance. So room = 6400.00 − member's deductible balance. Wait — "the out-of-network individual remainder, measured against the member's same single deductible balance". Hmm. So for OON claims, the deductible threshold is the OON individual threshold (6400.00), and the remainder is 6400.00 − member's deductible balance (the single balance that includes both IN and OON credits).
Wait, but there's a subtlety: the member's balance is a single balance. For an OON claim, we measure against the member's balance vs 6400.00. But also, the aggregate structure: for in-network claims, we measure the family remainder vs 6400.00.
Hmm, but there's an interaction: for an OON claim, do we also need the family remainder? The addendum says: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
So for OON claims: deductible_applied = min(allowed, 6400.00 − member's deductible balance). If member's balance ≥ 6400.00, deductible_applied = 0.
Hmm wait, but what about the aggregate structure for OON? The plan says AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. But the addendum says OON claims are measured against OON individual thresholds only. Hmm, this creates a question: can a member hit coinsurance on an OON claim before the family deductible (6400 IN) is met?
Let me re-read: "Structure ... AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
And the addendum: "out-of-network ... the out-of-network individual remainder, measured against the member's same single deductible balance." And "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim."
I think the intended reading: For OON claims, the deductible threshold is the member's single deductible balance measured against 6400.00 (OON individual). So a member can satisfy their OON deductible (6400.00 in credits on their own balance) and then get coinsurance on OON claims even if family total < 6400.00? Hmm, but the aggregate statement says "the plan pays no coinsurance for any member until total family credits reach the family deductible amount."
Hmm, but actually the addendum explicitly overrides: "the family amounts, which are in-network amounts, do not limit an out-of-network claim". So for OON claims, the limit is the member's own 6400.00 threshold. The aggregate language applies to in-network claims ("the plan pays no coinsurance for any member" — for in-network services presumably). Actually the aggregate statement says "the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." This is under the Deductible section describing the in-network structure. The addendum then clarifies OON handling.
Let me just carefully compute and see whether it matters.
Actually, let me think about it more carefully as I process the ledger.
Also note: the deductible balance and OOPM balance are separate accumulators. The deductible balance is the running total of deductible_applied; the OOPM balance is the running total of member_responsibility.
Now, when is coinsurance applied? "Coinsurance after deductible" — so a claim's member responsibility = deductible_applied + coinsurance on the portion of allowed above deductible applied. So member_responsibility = deductible_applied + (allowed − deductible_applied) × coinsurance_rate.
But under aggregate structure: for an in-network claim, if family deductible isn't met, deductible_applied = min(allowed, family remainder). If allowed > family remainder, then the excess gets coinsurance? Wait — under aggregate, "the plan pays no coinsurance for any member until total family credits reach the family deductible amount." Hmm, so if a claim straddles the threshold: part of the allowed goes to deductible (up to family remainder), and the rest gets coinsurance (since after that claim the family deductible is met). That's the standard interpretation: the deductible is met mid-claim, the remainder of the claim is subject to coinsurance.
So member_responsibility = deductible_applied + (allowed − deductible_applied) × rate, where rate applies when the deductible threshold is met for the portion above deductible_applied.
But wait — under aggregate structure with a straddling claim: the claim itself brings family credits to 6400, so the excess portion is after the deductible is satisfied, so coinsurance applies to the excess. Yes.
For OON: threshold is member's own 6400. If member's balance + allowed > 6400, then deductible_applied = 6400 − member balance, and excess gets 40% coinsurance.
Hmm wait, but there's another subtlety: what if the family remainder is smaller? For OON, family amounts don't limit. OK.
Also, for in-network claims under aggregate: what if the member's own balance exceeds... there's no individual deductible, so only family remainder matters. OK.
OOPM: Individual in-network 7000, family in-network 14000, OON individual 14000. "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."
Question: Which OOPM applies to a claim? The addendum says OON claims are measured against OON individual thresholds only. So for an OON claim, the OOPM threshold is 14000 (member's OOPM balance vs 14000). For in-network claims, the member's OOPM is 7000 individual... but what about the family OOPM 14000? Hmm.
The family OOPM: "Out-of-pocket maximum ... Family (in-network) 14000.00". Under aggregate, is the OOPM also aggregate? The plan document doesn't say the OOPM is aggregate or embedded; it just lists individual and family amounts. The task family rules say: "An OOPM ... Once reached, the plan pays 100% of the allowed amount for covered in-network services."
Hmm. The typical rule: a member's cost share stops when their individual OOPM is reached OR the family OOPM is reached (for family coverage, once family OOPM is reached, no member pays). Let me think about how to handle: "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 addendum says: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
Interesting: "out-of-network claims can carry ... the family balances past the family amounts; the balances are not capped at the in-network amounts." So the OOPM balances are not capped — they can exceed 14000 etc. But the threshold for stopping cost share...
For an in-network claim, the applicable OOPM threshold: the smaller of the member's individual remainder (7000 − member OOPM balance) and the family remainder (14000 − family OOPM balance)? That's the standard embedded OOPM approach. Hmm, but is the OOPM aggregate like the deductible? The plan says the deductible structure is aggregate; it doesn't say that for OOPM. Actually, for the deductible, "There is no individual deductible under this structure." For OOPM, individual amounts are listed, so presumably each member has an individual OOPM of 7000 (in-network) and the family OOPM of 14000 also caps total family cost share.
Let me compute the numbers and see whether these subtleties matter.
Let me process line by line. I'll track:
- Each member's deductible balance (single, includes IN and OON credits).
- Each member's OOPM balance.
- Family deductible balance (total of member deductible balances).
- Family OOPM balance (total of member OOPM balances).
Since deductible credits always equal part of member responsibility (deductible_applied is a component of member_responsibility), the OOPM balance ≥ deductible balance for each member. Actually member_responsibility = deductible_applied + coinsurance_amount (+ copay, but no copays here). So OOPM accumulates member_responsibility.
Line 1 — Claim 1 — 2026-01-07 — A — Generic retail pharmacy fill, IN.
Allowed 74.87. Not preventive. HDHP: subject to deductible.
Aggregate structure: family remainder = 6400 − 0 = 6400. deductible_applied = min(74.87, 6400) = 74.87.
Coinsurance: allowed − deductible_applied = 0. member_resp = 74.87, plan_paid = 0.
A deductible balance: 74.87. A OOPM: 74.87. Family deductible: 74.87. Family OOPM: 74.87.
Line 2 — Claim 2 — 2026-01-17 — C — Inpatient admission, OON. Allowed 10883.95.
Preventive? No — inpatient admission. OON, so subject to OON deductible and coinsurance.
OON threshold: member's single deductible balance vs 6400. C's deductible balance = 0. Remainder = 6400. deductible_applied = min(10883.95, 6400) = 6400.00.
Excess = 10883.95 − 6400 = 4483.95. Coinsurance 40% member: 1793.58. Let me compute: 4483.95 × 0.4 = 1793.58. Yes exactly 1793.58.
member_resp = 6400 + 1793.58 = 8193.58. plan_paid = 10883.95 − 8193.58 = 2690.37.
Check OOPM: C's OOPM balance before = 0. OON OOPM individual threshold = 14000. member_resp 8193.58 doesn't reach 14000, so no truncation.
C deductible balance: 6400.00. C OOPM: 8193.58.
Family deductible: 74.87 + 6400 = 6474.87. Family OOPM: 74.87 + 8193.58 = 8268.45.
Wait — but hold on. Under AGGREGATE structure, "the plan pays no coinsurance for any member until total family credits reach the family deductible amount." At the time of Claim 2, family credits = 74.87 < 6400. Does C get coinsurance on the OON claim? The addendum says OON claims are measured against OON individual thresholds only; family amounts do not limit an OON claim. So yes, C's own balance (0) vs OON threshold 6400: deductible_applied = 6400, and the excess gets 40% coinsurance. The addendum explicitly says family amounts don't limit OON claims. So this is the intended reading.
Hmm, but wait — "the out-of-network individual remainder, measured against the member's same single deductible balance" — the member's single deductible balance includes IN and OON credits. For C, balance = 0, remainder = 6400. OK.
Line 3 — Claim 3 — 2026-02-01 — C — Diagnostic lab, OON. Allowed 967.99.
C's deductible balance = 6400 ≥ 6400, so deductible_applied = 0.
Coinsurance 40%: 967.99 × 0.4 = 387.196 → 387.20 (round half up at the end; let me keep 387.196 for now, round at end). Actually the rule says round half up to the cent at the end of a calculation. For each claim, the calculation's end is the coinsurance amount. Let me be careful: 967.99 × 0.40 = 387.196. Rounds to 387.20.
member_resp = 387.20, plan_paid = 967.99 − 387.20 = 580.79.
OOPM check: C's OOPM balance = 8193.58. OON threshold 14000. 8193.58 + 387.20 = 8580.78 < 14000. OK.
C deductible stays 6400.00. C OOPM: 8193.58 + 387.20 = 8580.78.
Family deductible: 6474.87 + 0 = 6474.87. Family OOPM: 8268.45 + 387.20 = 8655.65.
Line 4 — Claim 4 — 2026-02-15 — A — Urgent care, IN. Allowed 255.34.
Family remainder (aggregate): 6400 − 6474.87 = negative → family deductible already exceeded (6474.87 ≥ 6400). So deductible_applied = 0.
Coinsurance 10%: 255.34 × 0.10 = 25.534 → 25.53. member_resp = 25.53, plan_paid = 229.81.
OOPM: A's OOPM = 74.87. IN individual OOPM = 7000; family OOPM = 14000; family OOPM balance = 8655.65 < 14000. So no truncation. member_resp 25.53 fine.
A OOPM: 74.87 + 25.53 = 100.40. A deductible: 74.87.
Family deductible: 6474.87. Family OOPM: 8655.65 + 25.53 = 8681.18.
Line 5 — Claim 5 — 2026-03-01 — A — ED visit, IN. Allowed 3545.18.
Family deductible met (6474.87 ≥ 6400), so deductible_applied = 0. Coinsurance 10%: 354.518 → 354.52. member_resp = 354.52, plan_paid = 3545.18 − 354.52 = 3190.66.
A OOPM: 100.40 + 354.52 = 454.92. Family OOPM: 8681.18 + 354.52 = 9035.70.
Family deductible stays 6474.87.
Line 6 — Claim 6 — 2026-03-07 — A — Allergy testing, IN. Allowed 911.89.
Deductible applied 0 (family met). Coinsurance 10%: 91.189 → 91.19. member_resp = 91.19, plan_paid = 820.70.
A OOPM: 454.92 + 91.19 = 546.11. Family OOPM: 9035.70 + 91.19 = 9126.89.
Line 7 — Claim 7 — 2026-03-19 — B — Ambulatory surgery, IN. Allowed 7845.50.
Family met. deductible_applied = 0. Coinsurance 10%: 784.55. member_resp = 784.55, plan_paid = 7060.95.
B OOPM: 784.55. Family OOPM: 9126.89 + 784.55 = 9911.44. Family deductible: 6474.87. B deductible: 0.
Line 8 — Claim 8 — 2026-03-28 — D — Ambulatory surgery, IN. Allowed 6750.63.
Family met. deductible 0. Coinsurance 10%: 675.063 → 675.06. member_resp = 675.06, plan_paid = 6075.57.
D OOPM: 675.06. Family OOPM: 9911.44 + 675.06 = 10586.50.
Line 9 — Claim 9 — 2026-04-11 — B — Inpatient, IN. Allowed 12250.27.
deductible 0. Coinsurance 10%: 1225.027 → 1225.03. member_resp = 1225.03, plan_paid = 11025.24.
B OOPM: 784.55 + 1225.03 = 2009.58. Family OOPM: 10586.50 + 1225.03 = 11811.53.
Line 10 — Claim 10 — 2026-04-27 — D — Inpatient, IN. Allowed 12224.51.
deductible 0. Coinsurance 10%: 1222.451 → 1222.45. member_resp = 1222.45, plan_paid = 11002.06.
D OOPM: 675.06 + 1222.45 = 1897.51. Family OOPM: 11811.53 + 1222.45 = 13033.98.
Line 11 — Claim 11 — 2026-05-10 — D — Annual wellness visit, OON. Allowed 664.62.
Preventive but OON → subject to OON deductible and coinsurance.
D's deductible balance = 0. OON threshold remainder = 6400 − 0 = 6400. deductible_applied = min(664.62, 6400) = 664.62. Coinsurance on excess = 0. member_resp = 664.62, plan_paid = 0.
OOPM check: D OOPM = 1897.51; +664.62 = 2562.13. Fine.
D deductible: 664.62. D OOPM: 2562.13. Family deductible: 6474.87 + 664.62 = 7139.49. Family OOPM: 13033.98 + 664.62 = 13698.60.
Line 12 — Claim 12 — 2026-05-17 — B — Generic pharmacy, OON. Allowed 30.19.
B deductible balance = 0. OON remainder = 6400. deductible_applied = 30.19. member_resp = 30.19, plan_paid = 0.
B deductible: 30.19. B OOPM: 2009.58 + 30.19 = 2039.77. Family deductible: 7139.49 + 30.19 = 7169.68. Family OOPM: 13698.60 + 30.19 = 13728.79.
Line 13 — Claim 13 — 2026-05-24 — D — Screening colonoscopy (no polyp), OON. Allowed 716.51.
Preventive but OON → OON deductible and coinsurance.
D deductible balance = 664.62. OON remainder = 6400 − 664.62 = 5735.38. deductible_applied = min(716.51, 5735.38) = 716.51. member_resp = 716.51, plan_paid = 0.
D deductible: 664.62 + 716.51 = 1381.13. D OOPM: 2562.13 + 716.51 = 3278.64. Family deductible: 7169.68 + 716.51 = 7886.19. Family OOPM: 13728.79 + 716.51 = 14445.30.
Hmm, family OOPM now 14445.30 > 14000. But the addendum says balances are not capped. The question is whether subsequent claims' member responsibility is truncated because family OOPM is reached. Let's think: "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services." And family OOPM 14000: once family OOPM is reached, typically no family member pays more. But the addendum says "out-of-network claims can carry ... the family balances past the family amounts; the balances are not capped at the in-network amounts." This suggests that the balances just keep accumulating; but does the family OOPM (in-network 14000) stop in-network cost share for members once family OOPM ≥ 14000?
Hmm. This is a real question. Let me re-read the plan:
"Out-of-pocket maximum
Individual (in-network) 7000.00
Family (in-network) 14000.00
Individual (out-of-network) 14000.00
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."
And the harness glossary: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services. Premiums and non-covered services never count toward it."
The addendum: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
I think this means: the balances themselves aren't capped (they keep tracking), but the thresholds still apply for truncating cost share. For an in-network claim, which thresholds apply? The member's individual in-network OOPM (7000) and the family in-network OOPM (14000). Hmm, but is the family OOPM a limit on in-network claims?
Hmm, actually, let me reconsider. The sentence "out-of-network claims can carry ... the family balances past the family amounts" — this is about OON claims pushing family OOPM past 14000. If the family OOPM were a truncation trigger for subsequent claims, then pushing past it via OON claims would still trigger truncation for subsequent in-network claims. The addendum doesn't explicitly say whether the family OOPM truncates.
Let me look at the task family rules again: "An OOPM ... Once reached, the plan pays 100% of the allowed amount for covered in-network services." The glossary says "Once reached" — reached by whom? "the ceiling on member cost share for the plan year".
Hmm. In standard HDHP design, the family OOPM works like: once the family OOPM is reached (aggregate), no member pays anything more. But here the deductible is aggregate; OOPM could be either. The plan lists individual and family OOPMs. The phrase "Once a member reaches the out-of-pocket maximum" focuses on the member's individual OOPM.
I think the intended mechanics, given the addendum, are:
- For an in-network claim: applicable OOPM threshold is... the member's OOPM balance vs 7000 (individual in-network), and possibly family OOPM balance vs 14000.
- For an OON claim: member's OOPM balance vs 14000 (OON individual). Family amounts don't limit OON claims.
For in-network claims, does the family OOPM limit? The addendum says "the family amounts, which are in-network amounts, do not limit an out-of-network claim" — implying family amounts DO limit in-network claims. So yes: for an in-network claim, the applicable OOPM remainder is the smal[empty response]Grader detail
json{
"reason": "response did not contain parseable JSON"
}33Claude Opus 4.8 · Anthropic143.5s · 12,817 out | 225.9s · 19,041 out | 180.0s · 15,849 out
Reasoning · 12,295 tokens
[omitted]json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "462.07",
"ending_oopm_a": "842.12",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8193.58",
"ending_deductible_d": "935.83",
"ending_oopm_d": "2833.34",
"ending_deductible_e": "91.19",
"ending_oopm_e": "91.19",
"ending_family_deductible": "7919.28",
"ending_family_oopm": "14000.00"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "462.07",
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "842.12",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8193.58",
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "935.83",
"ok": false,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "2833.34",
"ok": false,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "91.19",
"ok": false,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "91.19",
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "7919.28",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "14000.00",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}Reasoning · 18,274 tokens
[omitted]Looking at this ledger, the key dynamics are: the family deductible (6400 aggregate) is satisfied by Claim 2's out-of-network deductible credit, so all later in-network claims skip the deductible and go straight to coinsurance; and the family out-of-pocket maximum (14000) is repeatedly reached, capping member responsibility, with the two voids (Claims 3, 6) each temporarily reopening room that the next out-of-network claim exactly refills. By Line 17 the family OOPM is reached and stays reached (Claim 20's adjustment removes no credits since it is preventive), so Claims 19, 20, and 25 are all paid at 100%. Claim 20 is an in-network routine immunisation (preventive) regardless.
json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "462.07",
"ending_oopm_a": "842.12",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8193.58",
"ending_deductible_d": "935.83",
"ending_oopm_d": "2833.34",
"ending_deductible_e": "91.19",
"ending_oopm_e": "91.19",
"ending_family_deductible": "7919.28",
"ending_family_oopm": "14000.00"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "462.07",
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "842.12",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8193.58",
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "935.83",
"ok": false,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "2833.34",
"ok": false,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "91.19",
"ok": false,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "91.19",
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "7919.28",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "14000.00",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}Reasoning · 15,021 tokens
[omitted]Looking at this ledger, the key facts are: aggregate deductible (family threshold 6400, no individual in-network deductible), OON claims measured against the member's single balance against OON individual thresholds (6400 ded / 14000 OOP) and NOT limited by the family amounts, while in-network claims are measured against the family remainder and capped by the in-network family OOPM (14000).
The family deductible was met early (Claim 2 alone put it over 6400), so all subsequent in-network claims ran at 10% coinsurance. OON claims kept pushing the single family OOP balance up; by Line 18 the family OOP balance was 17909.137 — past the 14000 family OOPM — so every in-network claim from Line 19 on (19, 21, 22, 24, 25) is paid 100% by the plan. Claim 20 is an in-network routine immunisation (preventive, no cost share) and was corrected to 745.87.
json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.14"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.14",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}33Qwen3.8 Max · Alibaba767.8s · 30,000 out | 638.2s · 27,312 out | 676.9s · 30,000 out
Reasoning · 30,000 tokens
We need answer JSON. Need process ledger with plan rules. Need be careful. Need compute final components for claims 19,20,25 and ending accumulators. Let's reason thoroughly.
Plan: Trinity HDHP 3200. Plan year 2026.
Deductible:
Individual in-network 3200? But structure AGGREGATE: family deductible 6400. Plan pays no coinsurance for any member until total family credits reach family deductible. There is no individual deductible under this structure. However accumulators description says: in-network deductible_applied: family remainder alone (aggregate). But also says member's own accumulator and family accumulator both move on every claim that generates cost share. Under aggregate no member reaches coinsurance until family amount met. Need individual deductible accumulators? They report ending deductible per member. In aggregate, individual balances are tracked? It says credits accumulate to member balance and family balance. For in-network aggregate: deductible_applied lesser allowed and family remainder alone; but credit still accumulates to member's balance and family balance. So member deductible balance may exceed 3200? It says balances not capped at in-network amounts. But because aggregate family threshold 6400, total family credits can reach 6400. Member balances are sum of their deductible_applied? likely yes. OOP balance is member responsibility (deductible + coinsurance? out-of-pocket balance running total of member_responsibility). Need track per member and family OOP? Family OOPM 14000 in-network? But out-of-network individual thresholds? Need parse.
Out-of-network deductible individual 6400. In-network and out-of-network deductible credits accumulate to SINGLE member deductible balance. The amount above is threshold that balance measured against when service is out-of-network. Hmm for OON: deductible_applied measured against OON individual remainder, same single deductible balance. Family amounts in-network do not limit OON claim. Credits OON still accumulate to member balance and family balance.
OOPM: individual in-network 7000, family in-network 14000, individual OON 14000. Once member reaches OOPM plan pays 100% allowed for covered services remainder plan year. Need determine if separate OON OOPM? It says individual out-of-network 14000. Family in-network 14000. There is no family OON. The OOP balance is running total member_responsibility. Because OON thresholds higher, OON claims can carry member balance past in-network individual amount, family balances past family amounts; balances not capped at in-network amounts. Need use thresholds depending on network? This is tricky. For in-network claims, once member OOP balance reaches individual in-network OOPM 7000? Or family OOPM? Under aggregate deductible, family OOPM likely applies? Plan doc says OOPM individual in-network 7000, family in-network 14000. Once a member reaches OOPM plan pays 100% allowed for covered services for remainder plan year. It says a member reaches OOPM, individual. But family OOPM? Need infer. It lists family OOPM. Maybe family total OOPM ceiling for all members? But wording "Once a member reaches the out-of-pocket maximum" singular. Family OOPM likely total family cost share ceiling: once family total OOP reaches 14000, plan pays 100% for all. But also individual OOPM 7000: if one member reaches 7000, plan pays 100% for that member? Yet under aggregate HDHP? Need interpret from rules. Accumulator addendum: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This implies thresholds: member in-network OOPM 7000, family in-network OOPM 14000, OON individual OOPM 14000. For OON claims, measured against OON individual threshold only; family amounts do not limit OON claim. Credits OON accumulate to member balance and family balance. For in-network claims, measured against individual in-network OOPM and family OOPM? It says out-of-network claims measured against out-of-network individual thresholds only; family amounts, which are in-network amounts, do not limit an OON claim. So for in-network claim, applicable OOPM threshold likely smaller of member individual remainder and family remainder? Similar embedded? But aggregate? Need parse. The plan says OOPM individual 7000, family 14000. Once member reaches OOPM plan pays 100% allowed for covered services. Could mean individual. But why family OOPM? Usually aggregate family OOPM. For family, once total family OOP reaches 14000, plan pays 100 for all. And individual? For aggregate deductible, individual OOPM may also apply? But "There is no individual deductible" but individual OOPM still? It says individual (in-network) 7000. Family (in-network) 14000. We need decide how to apply. The accumulator addendum: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate); out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance." So for aggregate in-network deductible: only family remainder controls deductible_applied. But member accumulator still gets credit. For OOPM, not explicitly but likely analogous: in-network claim's cost share limited by member individual OOPM and family OOPM? Need derive. It 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 sounds individual only. But family OOPM exists; maybe for family total. The rules for ledger family: "A member's own accumulator and the family accumulator both move on every claim that generates cost share." "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." Thus for in-network claims, family amount can limit. So likely for in-network cost share, use both member individual OOPM and family OOPM; if either maxed, plan pays 100? For aggregate deductible, family deductible threshold only, no individual deductible threshold. For OOPM, maybe individual and family thresholds. Need implement.
No copays. Preventive in-network no cost share/no accumulators. OON preventive subject to OON deductible/coinsurance. Need identify preventive: Line 11 Annual wellness visit OON (preventive? Annual wellness visit likely preventive; but OON preventive subject to OON deductible/coinsurance per rules). Line 13 screening colonoscopy no polyp removed OON (preventive; OON subject). Line 20 routine immunisation in-network (preventive; no cost share/no accumulators). But adjustment to Claim 20: if preventive in-network, corrected allowed downward; still preventive, no cost share, no accumulator. Adjustment unwinds credits (none) and readjudicates no cost share. So claim 20 components all zero? Need confirm: Routine immunisation in-network is preventive required covered no cost share. Yes. Claim 20 member resp 0, plan paid allowed? "Preventive services in-network carry no cost share and move no accumulator." Plan pays 100% allowed? Member responsibility 0, plan_paid allowed? The rule says member_responsibility + plan_paid equals allowed amount of claim. For preventive in-network, plan_paid = allowed, member=0, deductible=0, coinsurance=0. Adjustment allowed 745.87, plan paid 745.87. But if original had posted? Original claim 20 was preventive, no accumulators, so no unwind. Final components from adjustment: allowed 745.87, plan paid 745.87. Good.
Need process all lines in order with adjustments/voids. Need determine exact accumulators and final on-book components for claims 19,20,25, and ending accumulators. Need track all claims. Need careful with voids: Void of Claim 3, Claim 6. Need unwind credits from accumulators as of void, not reprocess intermediate. Need track original credits and void effects. Adjustment none except Claim 20 preventive no credits. But need if adjustment to preventive? no effect.
Need decide OON cost sharing and how deductible/OOPM apply. Let's parse all plan doc:
Deductible:
- Individual (in-network) 3200
- Family (in-network) 6400
- Structure AGGREGATE — plan pays no coinsurance for any member until total family credits reach family deductible amount. There is no individual deductible under this structure.
- Out-of-network (individual) 6400
- 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.
OOPM:
- Individual (in-network) 7000
- Family (in-network) 14000
- Individual (out-of-network) 14000
- 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.
Cost share:
- Coinsurance after deductible, in-network 10/90
- OON 40/60
- no copays. Every covered service subject to deductible then coinsurance.
Preventive: in-network preventive required covered no cost share not subject to deductible, coinsurance, copay.
Basis: member cost share from allowed.
Adjustments/voids as described.
Accumulators addendum:
- A claim's deductible_applied is LESSER allowed and room left under deductible threshold that applies:
in-network: smaller of member individual remainder and family remainder (embedded), or family remainder alone (aggregate);
out-of-network: OON individual remainder, measured against member's same single deductible balance.
- Once applicable threshold met, deductible_applied 0.
- A balance is running total deductible_applied or member_responsibility. Because OON thresholds higher, OON claims can carry member's balance past in-network individual amount, and family balances past family amounts; balances not capped at in-network amounts.
- OON claims measured against OON individual thresholds only; family amounts, which are in-network amounts, do not limit OON claim. Credits OON still accumulate to member balance and family balance.
Important: Single member deductible balance: In-network and OON deductible credits accumulate. For in-network aggregate, threshold is family in-network 6400. But how does member's single balance interact? If member has OON deductible credits, do they count toward family in-network deductible? "Credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." Yes. So family balance includes OON deductible credits. For in-network claim, deductible_applied = lesser allowed and family remainder (family threshold 6400 - family balance). But if family balance includes OON credits, can accelerate in-network deductible. However, family balance can exceed 6400 due to OON claims (since OON not limited by family threshold); once exceeds 6400, family remainder zero. Good.
For OON claim: deductible_applied = lesser allowed and OON individual remainder. The OON individual threshold is 6400 measured against same single member deductible balance. If member balance includes in-network and OON deductible credits. If member balance >=6400, OON deductible met. If not, deductible_applied up to 6400-member_balance. But family balance may be >? Doesn't matter. Credits added to member and family balance.
OOPM: Need similar. Member OOP balance = running total member_responsibility (all cost share? likely deductible + coinsurance). Family OOP balance = sum? It says credits still accumulate to family balance. For OON, measured against OON individual threshold only. For in-network, measured against? likely individual in-network and family in-network? Need know if OON member responsibility counts toward in-network OOPM? It says OON claims can carry member's balance past in-network individual amount and family balances past family amounts; balances not capped at in-network amounts. That suggests OON member responsibility accumulates to same OOP balance, and can exceed in-network OOPM. For later in-network claim, if member balance is >7000 due to OON, does in-network individual OOPM considered met? Since balance past in-network individual amount, yes likely no further in-network cost share for that member (if individual OOPM applies). But if OON claims carry family balance past family OOPM, then later in-network claims no family cost share? It says family balances past family amounts. So yes. But OON claims themselves are not limited by family amounts; even if family OOP balance >14000, OON claim still cost shares up to OON individual 14000 for member? Hmm.
Need determine exact algorithm for OOPM for each claim. We can infer from deductible language. For deductible, thresholds: in-network family only (aggregate); OON individual. For OOPM, maybe:
- In-network claim: member cost share after deductible is limited by both individual in-network OOPM and family in-network OOPM. The applicable OOP remainder is smaller of member's individual in-network OOP remainder and family in-network OOP remainder? But under aggregate maybe family? However plan says individual OOPM 7000 and family 14000. In family plans, usually both apply: individual and family; once either individual or family met, relevant services paid 100. For aggregate deductible, individual deductible absent but individual OOPM may still? The plan explicitly lists individual OOPM. "Once a member reaches the out-of-pocket maximum" singular. It might mean individual OOPM. Family OOPM could be overall cap but not per-claim limit? Need implement likely as: For in-network claims, after deductible, coinsurance member responsibility is limited by the lesser of remaining member individual in-network OOPM and remaining family in-network OOPM. If member OOP balance >=7000 or family OOP balance >=14000, no coinsurance. But because OON can push balances above these, if balance > threshold, remainder zero. For OON claims, coinsurance limited only by member OON OOPM remainder (14000 - member OOP balance?), not family. But note OON individual OOPM is 14000, same as family in-network amount. If member OOP balance includes in-network and OON responsibility, can exceed 14000? It says balances not capped; OON claims can carry member balance past in-network amount; maybe not past OON amount? For OON claim, deductible_applied and coinsurance limited by OON OOPM threshold 14000: member responsibility cannot cause member OOP balance to exceed 14000? "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." The OON individual OOPM is 14000. So if member balance below 14000, OON cost share up to remainder; if balance >=14000, OON cost share 0. But if previous in-network OOP balance is 7000 (individual met) but OON threshold 14000 not met, OON claim still subject to cost share until 14000? Likely yes: OON claims measured against OON thresholds only; in-network individual amount doesn't limit OON. Thus member with 7000 in-network OOP still pays OON until total balance 14000? But if in-network individual OOPM met, plan pays 100 for covered services remainder? Conflict. It says OON thresholds separate; likely in-network OOPM only applies to in-network services. OON services have separate higher OOPM. So member can have in-network max met but OON not. For later in-network, no cost share; for OON, still cost share until OON max. This is common: separate in-network/out-of-network accumulators. But the text says in-network and out-of-network deductible credits accumulate to single member deductible balance. For OOP, maybe single balance too? It says balance running total member_responsibility, OON claims can carry member's balance past in-network individual amount. That suggests single balance, but thresholds differ by network. If balance >=7000, in-network no cost share; if balance <14000, OON may still cost share. Yes.
Family OOPM: For in-network, family balance threshold 14000. For OON, family amount does not limit. OON claims still accumulate to family balance, can carry past family amount. Later in-network, if family balance >=14000, no cost share. If individual balance >=7000, no cost share for that member. If both? yes.
Need track family OOP balance: sum of member_responsibility credits (all networks?) It says credits OON still accumulate to family balance. So family OOP includes OON responsibility. It can exceed 14000. For in-network claim, family OOP remainder = max(0, 14000 - family_oop_balance) maybe; if family balance >=14000, no cost share. Member OOP in-network remainder = max(0,7000 - member_oop_balance). For in-network coinsurance, member responsibility = min(allowed after deductible? Actually cost share = coinsurance amount, but limited by OOP remainders). Need calculate plan paid accordingly.
But also deductible_applied counts toward member responsibility and OOP balance. Deductible_applied is member responsibility (since no copay). Once deductible threshold met, coinsurance applies, also member responsibility. OOP balance includes both. For a claim that straddles deductible and OOP max? Need compute sequentially: allowed amount. First apply deductible remainder (network-specific) up to allowed. That amount member resp, plan paid 0, credits deductible and OOP. Then remaining allowed after deductible: apply coinsurance percentage, but limited by OOP remainders? But note deductible_applied itself also consumes OOP remainders. If OOP max already reached before claim, no deductible or coinsurance? Deductible threshold maybe met? If OOP max reached, plan pays 100; no deductible applied. But if deductible not met yet but OOP max reached impossible because OOP includes deductible; unless OON thresholds weird? Could have family OOP max reached but family deductible not? Since OOP includes deductible, if OOP >=14000, family deductible 6400 definitely met. Individual in-network OOP 7000 > deductible individual? But aggregate family ded 6400, individual OOP 7000; if member OOP 7000, family ded likely met? Not necessarily if member OOP includes OON coinsurance beyond ded; family ded may be met. Anyway.
For a claim, the order: deductible first, then coinsurance. OOPM ceiling on member cost share. If deductible_applied uses up remaining OOP max? E.g., member OOP remainder less than deductible remainder? But in-network individual OOP 7000 > family deductible 6400; family OOP 14000 > family deductible. For OON individual OOP 14000 > OON deductible 6400. So deductible remainder cannot exceed OOP remainder if starting from zero? But because OON claims can push balance past in-network thresholds, for in-network claim if member balance >7000, OOP remainder 0, so no deductible/coinsurance even if family deductible not met? Could that happen? Member balance >7000 due to OON, but family balance maybe >? OON credits to family too; if member >7000, family >7000 but may be <14000, family deductible 6400 likely met because member deductible credits? If member OOP >7000 includes deductible maybe family balance includes same; family deductible threshold 6400 likely met if OOP >7000? Not necessarily if OOP from OON coinsurance after deductible; deductible credits at least some. But family balance includes all member resp, not just deductible. Family deductible balance is running total of deductible_applied, not member_responsibility. It could be less than 6400 while memb[empty response]Grader detail
json{
"reason": "response did not contain parseable JSON"
}Reasoning · 26,815 tokens
We need answer JSON only. Need compute ledger with complex aggregate family deductible, embedded? Plan is Trinity HDHP 3200 aggregate. Need process lines in order, adjustments/voids. Need final components for claims 19,20,25 and ending accumulators.
Need parse rules carefully. We need model accumulators.
Plan:
- Plan year 2026.
- Deductible individual in-network 3200; family in-network 6400; STRUCTURE AGGREGATE — plan pays no coinsurance for any member until total family credits reach family deductible amount. There is no individual deductible under this structure.
- Out-of-network individual deductible 6400. 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.
- OOPM individual in-network 7000; family in-network 14000; individual out-of-network 14000. Once member reaches OOPM plan pays 100% allowed for covered services remainder year.
- Coinsurance in-network after deductible 10% member, OON 40% member. No copays. All covered services subject deductible then coinsurance.
- Preventive in-network no cost share no accumulators. OON preventive subject to OON deductible and coinsurance. Need identify preventive: Claim 11 annual wellness visit OON; Claim 13 screening colonoscopy OON? It says screening colonoscopy, no polyp removed, out-of-network. Is it preventive? In-network preventive no cost share, OON preventive subject OON deductible/coinsurance. Claim 20 routine immunisation in-network preventive. Probably Claim 11 and 13 are preventive? Need examine. Annual wellness visit likely preventive. Screening colonoscopy likely preventive. But OON preventive subject to OON deductible and coinsurance per rule. So not free; applies deductible/OOP. In-network preventive Claim 20: no cost share and no accumulator. But adjustment to claim 20? Original allowed 1243.12, corrected to 745.87. Since preventive in-network, no cost share/no accumulators before and after. Need report components 0? plan_paid allowed? For preventive in-network paid 100% allowed, no deductible/copay/coinsurance. Adjustment changed allowed, so final plan paid 745.87, member 0, ded 0, copay 0, coins 0. Need ensure adjustment unwinds credits: none. Good.
- Basis: cost share from allowed. Billed above allowed ignored in-network. For OON? It says amounts billed above allowed not member responsibility for in-network services. For OON maybe balance billing? But member cost share calculated from allowed. It doesn't explicitly say billed above allowed not member for OON; but allowed amount basis. Probably member responsibility = ded + coins based allowed, plan paid allowed - member. No extra. We only report components sum allowed.
- Accumulators:
* deductible_applied is lesser of allowed and room left under threshold that applies:
in-network: smaller of member individual remainder and family remainder (embedded), or family remainder alone (aggregate);
out-of-network: OON individual remainder, measured against member's same single deductible balance.
Once applicable threshold met, deductible_applied 0.00.
* balance is running total deductible_applied (for deductible) or member_responsibility (OOP balance). Because OON thresholds higher, OON claims can carry member balance past in-network individual amount, and family balances past family amounts; balances not capped at in-network amounts.
* OON claims measured against OON individual thresholds only; family amounts, which are in-network amounts, do not limit an OON claim. Credits an OON claim generates still accumulate to member's balance and family balance.
Need interpret aggregate family deductible and OON. In-network: aggregate family deductible 6400: no member reaches coinsurance until family credits reach 6400. Deductible_applied for in-network claim = lesser allowed and family remainder. But also maybe member individual remainder? Since aggregate no individual deductible; but there is individual in-network threshold 3200? It says no individual deductible under aggregate. But accumulator says in-network: family remainder alone (aggregate). So ignore individual in-network remainder. But member deductible balance? It accumulates deductible_applied. For OON, deductible_applied measured against member's single deductible balance threshold 6400 OON. That balance includes all deductible credits (in-network and OON). But in-network aggregate family threshold might be met earlier; still member balance can be less/greater. For OON claim, deductible_applied = lesser allowed and OON individual remainder = max(0, 6400 - member total deductible credits). It says family amounts do not limit OON claim. OON credits accumulate to member balance and family balance. If family deductible already met? Does not matter for OON; measured against individual OON threshold only. If member OON individual deductible satisfied (total deductible credits >=6400), OON ded applied 0 and coinsurance 40%, unless member OOPM met.
- OOPM: individual in-network 7000, family in-network 14000, individual OON 14000. Need track out-of-pocket balances. OOP balance running total of member_responsibility. Which threshold applies? It says Once a member reaches OOPM plan pays 100% allowed for covered services remainder plan year. But there are separate in-network and OON OOPMs? Document: OOPM individual in-network 7000, family 14000, individual OON 14000. Need determine cost share after member reaches OOPM. For in-network services: if member OOP balance? Are OON costs counted toward in-network OOPM? Usually separate accumulators? The text says out-of-pocket maximum individual (in-network) 7000, family (in-network) 14000, individual (out-of-network) 14000. Once member reaches OOPM plan pays 100% allowed for covered services remainder year. But which OOPM? Need infer. It also says balances are running total of member_responsibility (for an out-of-pocket balance). Because OON thresholds are higher, OON claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; balances are not capped at the in-network amounts. OON claims measured against OON individual thresholds only; family amounts, which are in-network amounts, do not limit an OON claim. Credits an OON claim generates still accumulate to member's balance and to family balance.
This suggests single OOP balance per member? Or maybe in-network and OON separate? It says balance is running total of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts. That implies one OOP balance, measured against threshold applicable to service: in-network claims measured against individual/family in-network OOPM? OON measured against OON individual OOPM? But once OOPM reached plan pays 100% allowed for covered services. Need exact.
Let's parse from plan doc:
Out-of-pocket maximum
Individual (in-network) ................ 7000.00
Family (in-network) .................... 14000.00
Individual (out-of-network) ............ 14000.00
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. It may mean there are separate in-network and OOPM balances? But accumulator addendum says "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This suggests same balance can exceed in-network threshold but if service is OON, threshold is OON (higher). For in-network claim, if member's OOP balance >= in-network individual OOPM or family OOPM? Need family OOPM maybe aggregate? It doesn't specify structure for OOPM. For deductible aggregate. For OOPM, individual and family. Likely family OOPM aggregate? Need decide. It says Once a member reaches the OOPM... individual. Family OOPM maybe total family cost share ceiling. But if aggregate deductible, family OOPM? We need track ending_family_oopm. likely sum member OOP balances? But maybe capped? They ask ending_family_deductible and ending_family_oopm.
Important to compute claims 19,20,25 and ending accumulators.
Need simulate all lines.
Potential tricky: aggregate family deductible: family total deductible credits from all in-network and OON? It says OON credits still accumulate to family balance. Family deductible threshold is in-network 6400. But for in-network claim deductible_applied is family remainder alone. For OON claim deductible_applied is OON individual remainder, and credits accumulate to family balance. So family deductible balance can be increased by OON claims, and can exceed family amount? "family balances past the family amounts; balances are not capped at the in-network amounts." So yes, family deductible balance running total of all deductible_applied, not capped. For in-network deductible_applied limited by room left under family threshold? If family balance already >=6400, ded applied 0 for in-network. If family balance below, ded applied lesser allowed and (6400 - family balance). Even if member individual balance high? For aggregate no individual. For OON, deductible_applied limited by member OON remainder (6400 - member total deductible balance). OON claim can generate deductible applied even if family deductible met, if member's own total deductible balance below 6400. It then adds to family balance (already maybe above). Good.
OOPM: Need model similar? Member OOP balance running total member_responsibility. In-network claims: if member's OOP balance? The individual in-network OOPM 7000 and family in-network 14000. Is family OOPM aggregate? The plan pays 100% after member reaches OOPM. The family OOPM likely total family member responsibility; once family total reaches 14000, all members? But doc says once a member reaches. Need maybe individual OOPM only for member, family total for reporting. In aggregate deductible HDHP, family OOPM may be aggregate too? But not specified. Need infer from addendum: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This refers to balances not capped. It implies thresholds: in-network individual amount, family amount; OON individual amount. For OON service, threshold measured is OON individual only; family amounts do not limit OON claim. So for an OON claim, member OOP balance can exceed 7000 and even family 14000? If member OON balance below 14000, cost share continues. For in-network claim, if member balance >=7000? Or family balance >=14000? Probably plan pays 100% if either member individual in-network OOPM met or family in-network OOPM met? Need decide.
The required ending_family_oopm likely running total of member responsibility, not capped? But if OOPM ceiling, family balance shouldn't exceed? They say balances not capped at in-network amounts because OON can carry past. So ending family OOPM can exceed 14000 if OON claims. We need report running total, not capped. Similarly deductible balances can exceed thresholds. They ask ending accumulators likely running totals (credits). Not capped. Need compute.
Need identify if OON preventive is subject to deductible and coinsurance. Yes. But annual wellness and screening colonoscopy maybe preventive but OON: subject OON ded/coins. If they are not preventive? Same cost share anyway because all covered services subject deductible/coins; no copays. Only in-network preventive free. So claim 11/13 treated normal OON (unless not covered? assume covered). Claim 20 in-network preventive free. Good.
Need process adjustments/voids exactly.
We need compute final components for Claim 19 (no adjustment), Claim 20 adjusted to allowed 745.87, Claim 25. Claim 20 is preventive in-network; adjustment re-adjudicates at corrected allowed; no cost share, no accumulator. But adjustment unwinds credits none. Need report plan paid corrected allowed. But consider if original claim 20 was processed when accumulators maybe not relevant; no cost share. Adjustment reduces allowed. It doesn't affect other claims. So Claim 20 final components 0 member, plan paid 745.87. Deductible 0, copay 0, coins 0.
Need compute claims before, voids, adjustment, to know accumulators at claim 19, 25.
Let's create model. We need careful rounding: round half up to cent at end of each claim? The instructions: Round half up to cent at end of calculation, not intermediate. But coinsurance percentages can produce fractional cents. We can compute exact decimals and round each component? In claims, member_responsibility and plan_paid should equal allowed to two decimals. Usually cost share rounded per claim. Need decide rounding method. They say round half up to cent at end of a calculation, not at each intermediate step. For each claim component likely calculate member coinsurance = allowed * pct, round half up at claim final. Deductible applied exact allowed cents. Member responsibility = deductible_applied + coinsurance_amount (rounded?) Should sum to allowed. Plan paid = allowed - member_responsibility. Need ensure components maybe coinsurance rounded. We'll use decimal with cents. Since allowed has cents. Deductible applied = amount up to remainder, exact cents. Coinsurance after deductible: member percent * (allowed - deductible_applied) perhaps; round half up. Then member_responsibility = deductible_applied + coinsurance rounded? If ded applied cents, coins rounded, sum cents. Plan paid = allowed - member_resp. Good. If member OOPM met, plan pays 100%, member 0.
Need track member deductible balance: running total deductible_applied. Member OOP balance: running total member_responsibility. Family deductible balance: running total deductible_applied for all claims? It says OON credits still accumulate to member's balance and family balance. Yes. Family OOP balance: running total member_responsibility for all claims? Probably yes. Need unwinds for void/adjustment: remove credits from every accumulator they touched: deductible credits and member responsibility. For preventive no credits. For void claim 3 and claim 6 remove their deductible applied and member resp from member and family. Does OOP balance remove member responsibility? Yes credits generated — its deductible credit and its member responsibility — removed from every accumulator they touched. Member responsibility touched OOP balances (member and family?). It says member's and family's. So remove member resp from member OOP and family OOP. Also deductible applied from member deductible and family deductible. Then void posts nothing. Adjustments similar: unwind original claim's credits, then re-adjudicate corrected values against accumulators as they stand. For claim 20 no credits.
Important: For a claim that generated deductible applied and coinsurance, member_responsibility includes both. OOP balance accumulates total member_responsibility. Deductible balance accumulates deductible_applied. Coinsurance amount does not credit deductible. Good.
Need consider OOPM effect before deductible? Once member reaches OOPM, plan pays 100%, no deductible applied? If OOPM met, member responsibility 0, deductible_applied? The addendum says deductible_applied is lesser allowed and room left under threshold; once threshold met, 0. But if OOPM met before deductible threshold? Can that happen? OOPM includes deductible and coinsurance; if member had enough cost share. If OOPM met, plan pays 100%; would claim generate deductible_applied? Since no member responsibility, likely no deductible credit? The rules say Once member reaches OOPM plan pays 100% allowed. So no member cost share and presumably no deductible applied? But deductible_applied is the amount member pays at allowed before coinsurance? If plan pays 100%, member doesn't pay, so no deductible credit. But addendum might mechanically compute deductible applied based on remaining deductible irrespective of OOPM? Need determine order. Usually if OOPM met, claim paid 100%, no deductible accumulators. "Once reached, plan pays 100% of allowed amount for covered in-network services." For covered services. So member_responsibility 0. Deductible_applied should be 0 because no member cost share. But if deductible not met? Could OOPM be met before deductible? In HDHP, OOPM >= deductible, but if OON threshold higher maybe member OOP balance can exceed in-network deductible but not OON deductible. For in-network, if member OOP balance reaches 7000, deductible probably already met? Individual in-network ded 3200, but aggregate family ded 6400. Member could have OOP 7000 while family deductible not met? With aggregate, one member can incur 7000 cost share while family ded not met? If family deductible 6400, total cost share to meet family ded is 6400; if one member pays 7000, family ded definitely met because their cost share includes deductible credits? Actually if one member has allowed > 7000 all subject deductible; first 6400 of family allowed goes deductible, then coins. Member's OOP can reach 7000 after family ded met. So deductible likely met. For OON, member OOP may reach 14000 while OON individual deductible 6400 met. So OOPM before deductible unlikely. But with voids/adjustments? Maybe not.
Need family OOPM? If family total OOP reaches 14000, do all subsequent in-network claims pay 100%? The doc says Once a member reaches OOPM. But family OOPM exists. It might mean family total. Need implement? Could affect claim 25 maybe? Need see totals. We need compute if family OOPM reached by claim 25? likely maybe not? Let's estimate. Many large claims. Family OOPM 14000 in-network, OON separate. Aggregate deductible 6400 then 10% coins in-network. OON claims 40% with individual OON ded 6400, OON OOPM 14000. There are multiple OON claims for C, A, E, D? Need simulate. Family total member responsibility might exceed 14000 due OON. But in-network family OOPM maybe only in-network cost share? Or total? The text says OON claims can carry family balances past family amounts, not capped. So family OOP balance includes OON and can exceed 14000. But does reaching family in-network OOPM stop in-network cost share? Maybe yes if family total OOP (including OON?) reaches 14000? But OON claims measured against OON thresholds only; family amounts do not limit OON claim. That suggests for an in-network claim, if family OOP balance >= 14000, plan pays 100%? But if balance includes OON, OON could push family over in-network family OOPM and then in-network claims free? The language: "out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." This could mean OON credits accumulate, but when later in-network claim is measured against family threshold, the balance includes OON credits, potentially satisfying it. But family OOPM is in-network amount. If OON cost share counts toward in-network OOPM? Usually no, separate. But this synthetic says balances are not capped, OON can carry past in-network amounts. It may intend single balance that is compared to applicable threshold. For in-network claim, compare to in-network thresholds (individual/family) using total baljson{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 30,000 tokens
We need answer JSON only. Need solve complex ledger. Need careful. Let's parse plan. We need final components for claims 19,20,25 and ending accumulators for each member/family.
Plan: Trinity HDHP 3200 synthetic.
Plan year 2026.
Deductible individual in-network 3200, family in-network 6400, AGGREGATE: plan pays no coinsurance for any member until total family credits reach family deductible. No individual deductible under this structure.
Out-of-network individual 6400. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The threshold for service is out-of-network if service OON. Hmm important: "The amount above is the threshold that balance is measured against when the service is out-of-network." Accumulators addendum: deductible_applied is LESSER of allowed and room left under deductible threshold that applies:
in-network: smaller of member individual remainder and family remainder (embedded), or family remainder alone (aggregate);
out-of-network: out-of-network individual remainder, measured against member's same single deductible balance.
Once applicable threshold met, deductible_applied 0.00.
Balance is running total deductible_applied. Because OON thresholds higher, OON claims can carry member balance past in-network individual amount, and family balances past family amounts; balances not capped at in-network amounts.
OON claims measured against OON individual thresholds only; family amounts, in-network amounts, do not limit an OON claim. Credits OON claim generates still accumulate to member balance and family balance.
OOPM: individual in-network 7000, family in-network 14000, individual OON 14000. Once member reaches OOPM plan pays 100% allowed for covered services remainder plan year. Need determine how OOP accumulators work for in-network vs OON? Text says out-of-pocket maximum individual in-network 7000, family 14000, individual OON 14000. "Once a member reaches the out-of-pocket maximum the plan pays 100% of allowed amount for covered services for remainder plan year." There may be separate in-network and OON OOP? They list individual OON 14000. The accumulators given: out-of-pocket balance is running total of member_responsibility. It says balances not capped at in-network amounts. Need infer thresholds. OON claims are subject to OON deductible and coinsurance. Do OON member responsibility amounts count toward in-network OOPM? Usually separate accumulators maybe. Prompt: "Out-of-network (individual) ............ 14000.00" and "Once a member reaches the out-of-pocket maximum..." It may mean there are separate OOP thresholds for IN and OON. But the family total OOP? They ask ending_oopm_a etc likely total member_responsibility balance? Need understand.
Family accumulators initial have deductible and out-of-pocket for each member and family total. The ledger updates accumulators. We need ending deductible and OOPM. For each member likely balance (running total) not threshold. But "ending_oopm_a" maybe out-of-pocket accumulator balance, not max. Need report amounts.
Need simulate all claims, voids, adjustment. Key intricacies: aggregate deductible for in-network; OON individual deductible uses single member deductible balance but threshold OON 6400. In-network deductible applies only family remainder (aggregate) 6400? Since aggregate, no individual deductible. But each member has deductible accumulator? They show individual deductibles initially. Under aggregate, member's own deductible? It says no individual deductible under this structure. Yet accumulator per member deductible probably tracks credits attributed to member; family total tracks total. In-network deductible_applied = lesser allowed and family remainder alone. So if family deductible not met, in-network claims apply to family deductible, credited to member. Member deductible balance increases too. OON deductible_applied = lesser allowed and OON individual remainder measured against same single deductible balance. Since single balance includes prior IN and OON credits? Yes. For OON service, threshold 6400; deductible room = max(0, 6400 - member's total deductible balance) (because single balance). But "out-of-network individual remainder" maybe 6400 minus balance. For in-network service under aggregate: family remainder = max(0, 6400 - family total deductible balance). But if member balance exceeds 3200 due OON? family balance may exceed 6400? It says balances not capped at in-network amounts. However in-network deductible_applied = family remainder alone. Family remainder measured against family in-network threshold 6400? Once family total balance reaches 6400, no more in-network deductible. If family balance >6400 due OON credits? Remainder is 0. OK.
Coinsurance: after deductible, IN 10% member, OON 40% member. No copays. Preventive: In-network preventive required covered no cost share, no deductible/coinsurance/copay, plan 100%, no accumulator movement. Out-of-network preventive is subject to OON deductible and coinsurance. Need identify preventive services: Claim 11 annual wellness visit OON: preventive? Annual wellness visit likely preventive? But rule says OON preventive subject to deductible/coinsurance. So not free. Claim 13 screening colonoscopy OON: preventive, subject OON deductible/coins. Claim 20 routine immunisation in-network: preventive, no cost share, no accumulator. Adjustment to claim 20: still preventive? It corrects allowed downward. In-network preventive no cost share; no accumulators. Original Claim 20 should have no cost share and no accumulator; adjustment unwinds credits (none) and re-adjudicates (none). So components all zero except plan_paid allowed? For preventive plan paid 100% allowed. Member responsibility 0. deductible_applied 0, copay 0, coinsurance 0. Need ensure adjustment allowed 745.87; plan_paid 745.87.
Need process all claims in order. Need decide treatment of void: unwinds credits from every accumulator they touched and posts nothing. For voided claim components all 0.00 per rule? For claims not asked except accumulators. Claim 3 voided at line 14, Claim 6 voided line16. Need unwind their credits. Also their plan payments etc not relevant except accumulators. But we need simulate.
Need define member responsibility and how OOP accumulator updates. "A claim's deductible_applied ... balance is running total of deductible_applied (for deductible) or of member_responsibility (for out-of-pocket balance)." So OOP balance is running total member_responsibility? But preventive no member responsibility. Once OOPM reached plan pays 100%. Need apply OOP max dynamically? Need see if any member reaches OOPM. Likely yes due large claims. Need track member OOP balances perhaps separate in-network and out-of-network thresholds. They ask single ending_oopm per member. Could be total member_responsibility accumulated across all? But there are IN and OON OOPMs. Need likely track "out-of-pocket" as member_responsibility total. In initial family accumulators only one out-of-pocket per member. They don't show separate IN/OON OOP. Yet plan has individual OON OOPM 14000. They may expect one OOP accumulator? But if one OOP accumulator, which threshold triggers 100%? Maybe in-network OOPM only for in-network services? OON has its own threshold. The text says "Out-of-pocket maximum: Individual (in-network) 7000, Family 14000, Individual (out-of-network) 14000. Once a member reaches the out-of-pocket maximum the plan pays 100%..." Could mean each member has an in-network OOP balance and out-of-network OOP balance. But initial accumulator only "out-of-pocket" not split. Also family total out-of-pocket. Addendum: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This suggests a single balance can exceed in-network threshold. It says OON claims can carry a member's balance past the in-network individual amount. If a single OOP balance, then once it reaches in-network OOPM 7000, would plan pay 100% for covered services? But OON claims have higher threshold 14000; how can carry past 7000 if threshold triggers? Maybe the in-network OOPM only limits in-network cost share; out-of-network cost share continues to OON OOPM. Single balance may track total, but threshold applied depends on network: for in-network claim, if member's OOP balance >= 7000, no cost share; for out-of-network claim, if OOP balance >= 14000, no cost share. That would allow OON claims to carry balance past 7000 if no IN claims after. For family: in-network family OOPM 14000; OON individual 14000. Family OOP balance can exceed 14000? They say family balances past family amounts. OON claims credits still accumulate to family balance. In-network claims after family OOP balance >=14000 maybe plan 100. But OON claims not limited by family OOPM (family amounts are in-network amounts, do not limit OON claim). So OON claims only check individual OON OOPM 14000? Need implement.
Deductible similarly: single deductible balance per member, single family deductible total. Threshold depends network: IN aggregate family 6400; OON individual 6400. Since OON threshold equals family IN threshold 6400 but individual. OON claims can carry member's deductible balance past in-network individual amount? There is no individual IN deductible under aggregate; but maybe balance can pass 3200 due OON? It says because OON thresholds higher, OON claims can carry a member's balance past the in-network individual amount, and family balances past family amounts; not capped. But here OON individual deductible is 6400, same as family IN. In-network individual 3200 exists only text but aggregate no individual. Yet OON claims can carry member balance to 6400; family total beyond 6400 if multiple OON? Yes OON credits accumulate to family balance and not limited by family 6400. In-network deductible after family total >=6400 zero.
Need compute all claims. Let's set up actors A,B,C,D,E. Track:
- mem_ded_balance[m] = total deductible_applied credits from all claims (not capped).
- fam_ded_balance = total deductible_applied credits from all claims? It says credits an OON claim generates still accumulate to member balance and family balance. So yes all deductible_applied adds to family too. Void unwinds.
- mem_oop_balance[m] = total member_responsibility? But likely for OOP max. Could need separate IN and OON? The initial only one. Need decide. Let's inspect wording: "Out-of-pocket maximum Individual (in-network) 7000 Family 14000 Individual (out-of-network) 14000 Once a member reaches the out-of-pocket maximum the plan pays 100%..." It doesn't explicitly say separate balances. Accumulator addendum: out-of-pocket balance running total of member_responsibility. Because OON thresholds are higher, OON claims can carry a member's balance past the in-network individual amount, and family balances past the family amounts; balances are not capped at in-network amounts. This strongly implies single balance and threshold depends on claim network? But if single balance reaches 7000 and next in-network claim, plan pays 100. If next OON claim, since OON threshold 14000, cost share continues until balance reaches 14000. That matches "OON claims can carry a member's balance past the in-network individual amount" only if after reaching 7000 you still process OON with cost share. If an IN claim after 7000 would be 0 and not carry. So single balance with network-specific thresholds. For family OOP: family total balance running total member_responsibility. In-network family OOPM 14000. For in-network claim, if family total OOP balance >=14000? Plan pays 100? Also individual IN OOPM 7000. For in-network claim, check member OOP balance >=7000 OR family total OOP >=14000? Since family OOPM in aggregate? Plan doc says once a member reaches OOPM plan pays 100 for covered services for remainder. But family OOPM also. Under embedded? Here deductible aggregate, OOPM maybe family too. Need infer from family accumulator. They ask ending_family_oopm. Likely family OOP max accumulator. In-network claims maybe stop when either individual or family OOPM reached. OON claims measured against individual OON OOPM only; family amounts do not limit OON. Addendum for deductible says OON claims measured against OON individual thresholds only; family amounts do not limit an OON claim. For OOPM not explicit but likely analogous: OON claims only individual OON OOPM. In-network claims measured against individual IN OOPM and family IN OOPM? We need determine if any such triggers affect claims.
Need compute to see. Let's simulate manually carefully with cents. Need round half up at end? For each claim coinsurance percentage may produce fractional cents. Need round to cent at each component? Rules: Round half up to cent at end of calculation, not each intermediate step. But claim components must be cents. In claims processing, member responsibility = deductible_applied + coinsurance after deductible (no copay). Allowed = deductible_applied + coinsurance + plan_paid? Member resp + plan paid equals allowed. Deductible applied is exact allowed or remainder. Coinsurance is percentage of amount after deductible. Need round member responsibility maybe to cent; plan paid = allowed - member resp. Need ensure components sum. If apply round half up at end of claim calculation. We'll keep high precision.
Need consider OOPM mid-claim: If a claim's member responsibility would exceed remaining OOP max, cap member responsibility to remaining? Standard. The prompt says once reaches OOPM plan pays 100% for remainder. For a claim crossing threshold, member cost share capped at remaining OOP limit. Need implement. Does OOP max cap member responsibility total for claim. Yes. Need track. Also deductible threshold crossing similarly deductible_applied lesser allowed and room left; then coinsurance on remaining after deductible. OOP max cap after that. Need use thresholds network-specific. For aggregate family deductible: in-network claim deductible room = family ded remainder (max 0, 6400 - family balance) but family balance can >6400 from OON; then 0. Does individual member OOP IN threshold check maybe before deductible? OOP max after deductible? Usually all cost share counts. If OOP max already met, plan pays 100, no deductible/coinsurance. Need check. If OOPM met, no deductible applied? Since plan pays 100 allowed, member responsibility 0, deductible_applied? The addendum says once applicable threshold met deductible_applied 0.00, including copay. But OOPM isn't deductible threshold. If OOPM reached, should deductible_applied be 0? Since no member responsibility; plan pays 100. Deductible credit is member responsibility? Deductible_applied is member paid and counts to OOP. If OOPM met, member pays 0, so no deductible. Need apply OOPM before deductible? If OOPM reached, no cost share and no accumulator movement. The plan says once reached plan pays 100 of allowed for covered services. So yes no deductible applied. For claim crossing OOPM, deductible may apply until OOP cap? Deductible_applied counts as member responsibility and toward OOP. If member has OOP room less than deductible remainder, then member pays only room? Does deductible_applied become capped by OOPM? Deductible_applied definition is lesser of allowed and deductible room, not mention OOPM. But if OOPM caps member responsibility, maybe plan pays rest, and deductible_applied could still be full? But if member doesn't pay full deductible, should deductible accumulator get credit? Usually only member paid amounts count toward deductible and OOP; if plan pays due OOPM, no deductible credit. If OOPM cap mid-claim, the portion above cap is plan paid, not deductible credit. So need cap member_responsibility and likely deductible_applied? Suppose allowed 1000, deductible room 1000, OOP room 100. If member pays 100, does deductible get 100 or 1000? In real, member's cost share capped, plan pays remaining; deductible credit should be 100? But deductible_applied defined as lesser allowed and deductible room, not OOP room. Yet member_responsibility equals deductible_applied if all deductible. But member_responsibility capped by OOPM would be less than deductible_applied, violating member responsibility plus plan paid equals allowed? If deductible_applied=1000, member_resp=100, plan_paid=900? Then member_resp+plan_paid=1000 allowed, okay, but deductible_applied > member_resp. Is deductible_applied not necessarily member responsibility? It says balance is running total of deductible_applied for deductible, of member_responsibility for OOP. Deductible credits may be based on allowed amount applied to deductible even if OOPM covers? Usually if OOP max met, no deductible applied. But the definitions don't explicitly cap deductible_applied by OOP. Need decide. Since they ask deductible_applied as claim component. In typical adjudication, if OOP max satisfied, plan pays 100%, no deductible/coinsurance. So deductible_applied 0. If crossing, cost share limited; deductible_applied should be actual member cost share allocated to deductible? The definition says deductible_applied is LESSER of allowed and room left under deductible threshold. It does not say limited by OOP room. But if OOP max has higher priority? Let's examine. "Out-of-pocket maximum: ceiling on member cost share for plan year. Once reached, plan pays 100% of allowed amount for covered in-network services." (Glossary says for covered in-network services; plan doc says covered services). "Member cost share is always calculated from allowed." "Deductible: amount member pays at allowed rate before coinsurance begins." If OOPM reached, member pays 0, so not deductible. The accumulator addendum: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." This could allow deductible_applied to exceed member_responsibility if OOP cap? But then deductible balance would include plan-paid amounts? Unlikely.
Need see if any claims cross OOPM in this ledger; maybe yes. Need exact.
Let's simulate without OOPM caps first to see.
Line1 Claim1 A IN allowed 74.87. Family ded balance 0, aggregate family remainder 6400. Deductible_applied = min(74.87,6400)=74.87. Coinsurance 0. Member resp=74.87. Plan paid 0. A ded bal 74.87, fam ded 74.87. OOP A +74.87, family OOP? likely +74.87. Need track.
Line2 Claim2 C OON allowed 10883.95. OON individual deductible threshold 6400 measured against C's single deductible balance (0). Deductible_applied = min(10883.95, 6400 - C bal? 6400)=6400. Remaining allowed after deductible = 4483.95. OON coinsurance 40% = 1793.58 exactly? 4483.95*0.4=1793.58. Member resp = 6400+1793.58=8193.58. Plan paid = allowed - MR=2690.37. OOP C +8193.58. Ded C 6400, fam ded +6400 => fam ded 6474.87. Note family balance >6400? Yes 74.87+6400=6474.87. OON credits accumulate to family, can exceed. For future IN deductible family remainder max(0,6400-6474.87)=0. Thus family aggregate deductible met due C OON? The family IN deductible threshold is 6400; balance is 6474.87, so no future IN deductible. Is that intended? "OON claims can carry ... family balances past family amounts" and in-network deductible uses family remainder alone. So yes one OON claim can meet family IN deductible due credits? But OON threshold individual 6400, family IN 6400. Since C OON deductible credit 6400 plus A 74.87, family balance >6400. Then all subsequent IN claims no deductible. Seems plausible. Need consider if OON deductible credits should count toward in-network family deductible? The text says credits an out-of-network claim generates s[empty response]Grader detail
json{
"reason": "response did not contain parseable JSON"
}33Qwen3.8 Flash · Alibaba255.2s · 27,055 out | 559.4s · 30,000 out | 283.8s · 30,000 out
Reasoning · 26,558 tokens
We need solve plan-year ledger carefully. Need output JSON only. Need compute accumulators and final components for claims 19,20,25.
We need parse synthetic plan. Trinity HDHP 3200. Plan year 2026. Deductibles: individual in-network 3200 but structure AGGREGATE: no individual deductible, family deductible 6400. OON individual deductible 6400. Single member deductible balance for both IN and OON thresholds; OON claims measured against OON individual thresholds only; family amounts don't limit OON, but credits still accumulate to member and family deductible balances.
OOP max: Individual in-network 7000, Family in-network 14000, Individual OON 14000. Once member reaches OOP max plan pays 100% for covered services for rest of year. Need track member OOP balance and family OOP balance? OON thresholds: individual OON 14000. Family amounts in-network amounts? For OON, likely individual OON only; family in-network OOP max does not limit OON? But credits accumulate to family balances? It says once a member reaches the out-of-pocket maximum the plan pays 100%... OOP max individual in-network 7000, family in-network 14000, individual OON 14000. Need determine application for OON: measured against individual OON threshold only? likely family OOP max not limit OON. But credits accumulate to family balances. However if family reaches in-network OOP max? Does plan pay 100% for in-network services; not for OON? We need track ending family OOP likely sum of all member responsibility? The problem asks ending accumulators every member and family: ending_deductible_a etc and ending_oopm_a, ending_family_oopm. Need calculate.
Cost share: coinsurance after deductible IN 10% member /90%; OON 40% member/60%. No copays. Preventive: IN preventive no cost share and no accumulators. OON preventive subject to OON deductible and coinsurance.
Basis allowed. ADJUSTMENT: unwind named claim's credits from every accumulator they touched and readjudicate at corrected values against accumulators as they stand at adjustment. Claims between not reprocessed. VOID unwind and post nothing. Only named claim affected.
Process in order. Need consider preventive classification: Generic retail pharmacy fill not preventive? No. Inpatient, diagnostic lab, urgent care, ED, allergy testing, ambulatory surgery, annual wellness visit OON preventive? Annual wellness visit is likely preventive. OON preventive subject to OON deductible/coinsurance. Screening colonoscopy no polyp removed is preventive? OON preventive subject to OON deductible/coinsurance. Routine immunization IN preventive? likely required to be covered without cost share? In-network preventive required to be covered no cost share. But is immunization preventive? Likely yes. Need classify "Annual wellness visit" as preventive. "Screening colonoscopy, no polyp removed" preventive. "Routine immunisation, in-network" preventive. If OON preventive subject OON deductible/coinsurance.
Need track accumulators precisely.
Definitions:
- deductible_applied per claim = lesser of allowed and room left under applicable deductible threshold. For aggregate in-network: family remainder alone? For an IN claim: room left under aggregate family deductible. Since no individual deductible. However it says embedded? "Under an aggregate structure no member reaches coinsurance until family amount met." And accumulator rules: in-network ... smaller of member individual remainder and family remainder (embedded), or family remainder alone (aggregate). So for IN claim deductible_applied = min(allowed, family deductible remaining). Out-of-network: individual OON remainder, measured against member's same single deductible balance. A member has a single deductible balance accumulating all IN and OON deductible credits; threshold for OON claim is 6400. For IN aggregate, threshold is family balance? But member deductible balance also? Need track individual deductible accumulators? The initial says FAMILY ACCUMULATORS with per member deductible and family total. Ending asks per member deductible. Under aggregate no individual deductible, but they may track member deductible credits? It says member's own accumulator and family accumulator both move on every claim generating cost share. For IN aggregate, member own deductible accumulator? Hmm: A (subscriber) deductible accumulator may represent member's deductible credits? Under aggregate no individual deductible threshold, but member's deductible accumulator likely credits (used for OON threshold). Need track per-member deductible balance (single balance for IN+OON) and family total deductible balance. Also member and family OOP balances.
For IN claims under aggregate: deductible_applied = min(allowed, family_deductible_remaining = max(0, 6400 - family_total_deductible_balance)). If family threshold met, deductible_applied=0, coinsurance after deductible.
For OON claims: deductible_applied = min(allowed, max(0, 6400 - member_deductible_balance)). But family deductible? OON claim credits still accumulate to member and family balances. If family in-network deductible not met and member OON deductible threshold met? OON threshold only member 6400. Once OON deductible met (member balance >=6400), deductible_applied for OON is 0, coinsurance. The family in-network deductible doesn't apply to OON. But does OON deductible credit reduce family deductible balance too? Yes, credits generated accumulate to family total deductible. But for IN aggregate, family deductible threshold is total credits including OON? It says single member deductible balance. Family amounts do not limit OON but credits accumulate to family balance. So OON deductible_applied may add to family deductible balance and thus help satisfy family aggregate for future IN.
OOP: once a member reaches OOPM plan pays 100% covered services for rest year. Need track individual OOP balances. In-network OOP threshold likely individual in-network 7000? But also family in-network 14000? Does family OOP max matter? Typically family OOP max: when family total OOP reaches family max, plan pays 100% for any member? But under this plan document, "Once a member reaches the out-of-pocket maximum the plan pays 100% of allowed amount for covered services". It names individual OOPM and family OOPM. Need determine if family OOP max caps individual? It might: family OOP max is ceiling on member cost share for family, so once family total reaches family OOPM, plan pays 100% for all covered services? But wording says a member reaches OOPM; family OOPM maybe limit for family. Need use typical: individual OOPM for individual, family OOPM for family total. However they only ask ending_family_oopm. Could be sum of member responsibilities capped by family OOPM? Need reason.
Rules: "Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services." That is glossary. For family: family in-network OOPM 14000. If reached, plan pays 100% for covered in-network services for remainder. The plan doc also has individual IN 7000 and family IN 14000. So likely track both individual IN OOP balance (member_responsibility for IN services? maybe all services?) and family IN OOP balance (sum member_responsibility for IN services? or all?). The OON claims subject to individual OON 14000. The glossary says OOPM ceiling on member cost share for plan year. Once reached, plan pays 100% of allowed for covered in-network services (only says in-network? Actually glossary says in-network services). But plan doc says Once a member reaches the out-of-pocket maximum plan pays 100% of allowed for covered services (not restricted). We need decide OON OOP max and family OON. There is Individual OON OOPM 14000. No family OON OOPM.
Because OON claims: measured against OON individual thresholds only; family amounts do not limit OON claim. For OOP? Similar likely OON claims measured against OON individual OOPM only. Family in-network OOPM doesn't limit OON. Credits accumulate to family balances (probably family OOP total?) The ending_family_oopm likely should include all member responsibility (including OON) or only IN? Let's inspect wording: "ending_deductible_a, ending_oopm_a (for A (subscriber)) ... ending_family_deductible, ending_family_oopm". They likely want accumulated deductible credits and OOP credits for each member and family total. For OOP accumulators initial includes member and family total. In health plan, OOP accumulators generally include covered in-network and sometimes OON member responsibility (subject to caps). We need compute final balances after adjustments. We must cap? "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." It says balances running totals, not capped at in-network amounts? For deductible: because OON thresholds higher, balances can carry past in-network individual/family amounts; not capped. For OOP? It doesn't explicitly say not capped at in-network amounts? It says deductible balances not capped. For OOP balances likely can exceed thresholds? But once reached, plan pays 100%, so member responsibility stops at OOPM? However under family aggregate OOPM? Need track. If OON individual OOPM 14000; member OOP can reach 14000 and no more member responsibility. For IN, individual OOPM 7000 and family OOPM 14000. The family OOPM might cap further member responsibilities; if family reaches 14000, no more member cost share for in-network claims. But member OOP may not individually reach 7000. Do we stop member responsibility at family OOPM? In typical benefit yes, once family deductible/OOP max met, plan pays 100% for all members? Actually family OOPM: total out-of-pocket for family cannot exceed. When family OOPM reached, plan pays 100% of covered services. So need apply family OOP cap to IN claims (and maybe all claims) but OON individual thresholds only. But plan doc "Once a member reaches the out-of-pocket maximum" and "Individual (in-network), Family (in-network)". Could imply if member hits individual, plan pays 100% for that member; if family hits family, plan pays 100% for family? Let's analyze likely intent from harness. They ask ending family OOP, so yes. They might expect family OOP balance sum of member responsibilities, capped by family OOPM? The family accumulator initial is sum? Need compute.
Maybe need apply OOP maximum on member level: For a given claim, before cost share, check whether member's OOP balance has reached applicable OOPM threshold. If yes, member responsibility=0, plan pays allowed. Also check family OOP balance threshold for in-network aggregate? If family reached 14000, plan pays 100% for IN? But if individual member hasn't reached 7000, still? Family OOPM is a ceiling on member cost share? Hmm.
Let's parse plan:
Out-of-pocket maximum
Individual (in-network) ................ 7000.00
Family (in-network) .................... 14000.00
Individual (out-of-network) ............ 14000.00
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.
This could mean each individual has an OOPM; IN individual threshold 7000 for IN services, OON individual threshold 14000 for OON. Family IN 14000? The "Family (in-network)" is family OOP max. Once a member reaches the OOPM? Maybe the member's individual amount; family amount maybe aggregate for family? But they ask ending family oopm so track. Under aggregate deductible, they mention family total. For OOP, likely track both individual and family OOP balances and apply family OOPM as a ceiling on total member cost share. But OON claims measured against OON individual thresholds only.
Could use: For IN claims, room to IN individual OOPM = max(0, 7000 - member_in_OOP_balance?) and room to family IN OOPM = max(0,14000 - family_in_OOP_balance?), member responsibility cannot exceed smaller? But if individual and family balances same? They ask one ending_oopm_a per member, not separate IN/OON. We need know if member OOP balance is combined all services? If a member hits individual IN OOPM (7000) due to IN services, plan pays 100% for covered services; does it also pay 100% for OON? There is individual OON OOPM 14000. Probably no, OON has its own max. But the wording "covered services" could include OON? They specify Individual OON OOPM 14000. Likely separate thresholds based on network. For ending member OOPM maybe running total of all member responsibility regardless network (could exceed 7000 due OON). The rule: balances are running total of member_responsibility (for OOP balance); OON thresholds higher, out-of-network claims can carry a member's balance past in-network individual amount and family balances past family amounts; balances not capped at in-network amounts. Wait that sentence is under deductible? Let's read:
"A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
This explicitly says balances (deductible or OOP) not capped at in-network amounts because OON thresholds higher. So ending OOP can exceed in-network individual/family thresholds. This means we don't cap balances at thresholds; we just compute member responsibility according to thresholds but OON can carry past IN threshold. If a member reaches IN individual OOPM, does that stop IN cost share? If they continue OON, their total OOP balance may exceed 7000. But if we use a single member OOP balance for all services, then once total >7000 from OON, does that mean they have reached IN OOPM and stop IN cost share? Maybe. The OON thresholds measured against same single balance? For deductible yes same single member deductible balance. For OOP likely same single OOP balance? Initial accumulator only one OOP per member. But there are IN and OON thresholds. If OON claims can carry member's balance past IN individual amount, that suggests a single OOP balance used, and for future IN claims if balance >= IN threshold, plan pays 100%? But OON threshold higher means if member has reached IN threshold, for OON claims they may still have cost share until balance reaches OON threshold. So a single OOP balance with different thresholds by service network. Family balances similarly can be carried past IN family amounts by OON credits. Good. So use combined member OOP balance (sum of member responsibility for all claims) and combined family OOP balance (sum member responsibility all claims). For IN claims, cost share limited by individual IN OOPM and family IN OOPM? For OON claims limited by individual OON OOPM only (family not limit). But the family OOP balance includes OON credits and can exceed 14000. For future IN claims, family OOP room measured against family IN threshold using total family OOP balance. This matches "family balances past family amounts".
But need careful: If family OOP max is reached, plan pays 100% for all members? Since single family OOP balance and family IN threshold. For IN claims, if family OOP room left = 0, member responsibility=0 for that claim? But individual IN OOP room also? Typically yes whichever first: individual or family. Need determine if member's individual IN threshold and family IN threshold both can limit cost share. For a claim, the maximum member responsibility before plan pays? If deductibles satisfied, member coinsurance 10% of allowed. But OOP caps may limit. If applying both individual and family caps, cost share = min(coinsurance_amount, individual_OOP_room?, family_OOP_room?). But if both cap, and one member has individual cap left 500 but family cap left 1000, member can only pay 500 then plan pays rest. If family cap left 100 but individual room 500, member can pay 100. This is typical. But is family OOP max applied per claim? yes.
However the plan doc wording "Once a member reaches the out-of-pocket maximum" might not mention family OOP max; but glossary says OOPM ceiling member cost share. Family amount exists. We need apply. Let's see if it matters in this ledger; family OOP might never reach 14000? Let's compute approximate. OON large member responsibility could cause family OOP over 14000. Need know whether to stop future claims. Let's calculate. If we don't cap family OOP, future cost shares continue. If cap, many later claims zero. Which expected?
Let's do full ledger under possible interpretations.
Start all balances 0.
Constants:
DIN fam threshold 6400.
DOON ind threshold 6400.
OOP individual IN threshold 7000.
OOP family IN threshold 14000.
OOP individual OON threshold 14000.
No IN individual deductible, only family aggregate. For IN deductibles: room = max(0, 6400 - family_ded_total). For OON deductibles: room = max(0, 6400 - member_ded_balance). For deductible credit, both member and family deductible balances increase by deductible_applied. For IN, member deductible balance too? Since "A member's own accumulator and family accumulator both move on every claim that generates cost share." Under aggregate no individual deductible threshold, but for ending per member deductible, likely increase member_ded by IN deductible_applied as well (it contributes to OON threshold). So yes.
For cost share:
- Preventive IN: member=0, deductible=0, coins=0, plan=allowed. Move nothing. (For Claim 20 adjusted from preventive? Routine immunization preventive IN, no cost share; adjustment allowed 745.87, still preventive, no move. Claim 20 final allowed 745.87, member=0 plan=745.87.)
- OON preventive: NOT exempt: subject to OON deductible/coinsurance.
- Other IN non-preventive: deductible up to family room; after deductible, coinsurance 10%, but OOP caps (individual IN/family IN). Note if family deductible not met, entire deductible part counts as member responsibility and OOP. If partial? deductible_applied = min(allowed, fam room). Then allowed remaining = allowed - deductible_applied; coins = 10% remaining if family deductible now met? Wait if deductible_applied uses all allowed because fam room < allowed, after this claim family deductible met. For the portion allowed beyond room, is coinsurance 90/10 or is deductible applied first then coins? Yes. Deductible applies to first room, then remaining subject to coinsurance. Member cost share = deductible_applied + coinsurance on remainder. If family room was zero, deductible_applied 0 and entire allowed coinsurance.
- OON: deductible up to member OON room. Remainder subject to 40% coinsurance. OON deductible not family; but family deductible total increases. OOP caps: individual OON room if combined OOP threshold? likely yes. If member reaches OON OOP threshold, no further member responsibility for OON. For IN, individual IN threshold lower. Need decide combined OOP balance. If using combined OOP balance, room for a claim depends on network threshold and whether OON claims can be charged after IN threshold. If member OOP balance 7000 due IN, IN room 0; OON room = 14000 - 7000 = 7000, so OON still can cost share. If OON balance 10000, IN room 0 (because >7000), OON room 4000. That fits. Family OOP balance: if >14000 due OON, IN room 0; OON unaffected. Good.
Need process void/adjustments: unwind credits from every accumulator they touched and readjust at current values. For claim 3 void: claim 3 OON lab for C. It had deductible_applied and member responsibility maybe. We need reverse both member and family deductible and OOP balances it touched. Claim 3 processed after Claim 2. Need compute initial values at line3; then at line14 unwind. Claims between processed not reprocessed. Then continue. If adjustment, unwind then recompute allowedjson{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8430.86,
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}Reasoning · 30,000 tokens
We need answer JSON only. Need solve plan-year ledger carefully. We have plan document aggregate family deductible structure? Need process all lines to final accumulators and report claims 19, 20 adjusted final, 25. Need understand OON preventive? In-network preventive no cost share. OON preventive subject to OON deductible and coinsurance. Need track deductible balances aggregate: family deductible threshold 6400, individual in-network no separate deductible? But out-of-network individual deductible threshold 6400, single member deductible balance. Need careful.
Plan doc: Trinity HDHP 3200.
Deductible:
Individual (in-network) 3200? But Structure: AGGREGATE — plan pays no coinsurance for any member until total family credits reach family deductible amount. There is no individual deductible under this structure. OON (individual) 6400. In-network and OON deductible credits accumulate to a SINGLE member deductible balance. The amount above is threshold that balance is measured against when service OON.
So aggregate family in-network: family total deductible credits threshold 6400 before any coinsurance (member pays 100% allowed until family deductible met? likely deductible applied up to family remainder; member_responsibility = deductible_applied; plan paid 0 until family deductible met. There is no individual deductible. But OON individual: each member has single deductible balance (credits accumulate). Threshold for OON services is 6400 (individual OON deductible). For in-network aggregate, family total deductible credits threshold 6400? The family total deductible balance includes both in-network and out-of-network deductible credits? It says In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. Family total? Need interpret accumulators.
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... Under an aggregate structure no member reaches coinsurance until the family amount is met." So we track member deductible accumulators and family deductible accumulator, and OOP accumulators. For aggregate family, in-network deductible_applied measured against family remainder only; no individual deductible for in-network. But OON deductible_applied measured against OON individual remainder, against member's same single deductible balance. The threshold for OON individual 6400. Family threshold in-network aggregate 6400. If OON deductible credits accumulate to member deductible balance and family balance. Need distinguish member deductible balance and family deductible balance? Yes ending_deductible per member likely member deductible accumulator? But aggregate no individual deductible? However OON individual threshold uses member deductible balance. What is ending_deductible_a? Likely accumulator balance of deductible credits applied for that member (member's deductible accumulator). For aggregate no member coinsurance threshold but still track member balances as per addendum. It might be running total of deductible_applied by member. For family total same.
Need process claims. Need know if preventive claims: OON preventive subject to OON deductible and coinsurance. So annual wellness visit OON and screening colonoscopy OON are covered but cost-share per deductible/coins. In-network routine immunization preventive? Generic pharmacy? Emergency? Urgent? Need classify preventive. Preventive care: in-network preventive services required to be covered without cost share paid 100%. Does that include annual wellness visit, screening colonoscopy? These are OON so subject to OON deductible/coinsurance. Routine immunization in-network? Vaccinations often preventive covered without cost share? In synthetic, likely routine immunization in-network preventive? Need decide. Annual wellness visit OON, screening colonoscopy OON. Allergy testing? diagnostic lab? Not preventive. In-network emergency/urgent/pharmacy/surgery/inpatient/primary/physical therapy all cost-share subject to deductible/coinsurance (no copays). What about "generic retail pharmacy fill" could be preventive? Not necessarily; every covered service including office visits, emergency care, retail pharmacy subject to deductible then coinsurance explicitly: "This plan has no copays. Every covered service, including office visits, emergency care, and retail pharmacy, is subject to the deductible and then coinsurance." That overrides preventive? Preventive care separate: In-network preventive services required... no cost share. But pharmacy not preventive unless generic maybe not. So treat pharmacy as normal deductible/coins.
"Routine immunisation" likely preventive in-network? Is vaccination a covered preventive service without cost share? In many ACA preventive includes vaccines. The plan says in-network preventive services required to be covered without cost share are paid 100%. Need identify if "Routine immunisation, in-network" is preventive. Likely yes. If so no cost share, moves no accumulator. However note every covered service including retail pharmacy subject to deductible/coinsurance? That statement says every covered service, including office visits, emergency care, and retail pharmacy, is subject to deductible and coinsurance. That seems contradict preventive if immunization is covered service. But preventive care says in-network preventive services required to be covered without cost share are paid at 100% not subject. The "Every covered service" probably means all non-preventive covered services? It says including office visits, emergency care, and retail pharmacy, which are typically subject. Routine immunization may be preventive and exempt. We must infer. Need be careful because Claim 20 adjustment. If Claim 20 is preventive no cost share, adjustment to allowed amount doesn't change accumulators. But if non-preventive, deductible/coins changes. Need likely classification.
Need report FINAL components on books for Claims 19, 20, 25. If Claim 20 adjusted, report components as re-adjudicated by adjustment. Need unwind original Claim 20 credits and re-adjudicate corrected allowed against accumulators at adjustment point. Important: Claim 20 originally line 20 in-network; adjustment line 23. Need unwind credits from all accumulators touched and re-adjudicate at corrected values against accumulators as they stand after lines through 22? "Claims processed in between are not reprocessed". Need process order: line 20 original updates accumulators; line 21,22 processed; line 23 adjustment unwinds original claim's credits and re-adjudicates at current accumulators (after line22 with original line20 still included? The adjustment line: "When a line is an adjustment to an earlier claim, the credits that claim generated — its deductible credit and its member responsibility — are removed from every accumulator they touched (the member's and the family's), and the claim is adjudicated again at its corrected values against the accumulators AS THEY STAND at the point the adjustment is processed." "claims processed in between are not reprocessed".
This is subtle: At point adjustment processed, accumulators include original claim20 plus line21/22. We remove original claim20 credits, then current accumulators are before claim20 but after lines 1-19,21,22 (but line21 and line22 processed with claim20 included at time, yet not reprocessed). Then adjudicate corrected claim20 against those. Then line24/25 after. So line21 and line22 results stand, even if claim20 removed would have changed them (if in-network aggregate could change deductible state). But if claim20 adjusted, we need know its credits and their accumulators. Need unwind only original Claim20 credits. Original Claim20 could be preventive no credits (if immunization) -> adjustment no effect. But if nonpreventive, it had deductible and member responsibility. Need know state.
Need simulate with potential classification of immunization. Let's decide later.
Need track OOPM balances: member OOP and family OOP from member_responsibility (deductible + coins) for covered services. Preventive in-network no OOP. OON preventive still cost-share OOP moves. Accumulator thresholds: individual OOPM in-network 7000; family in-network 14000; individual OON 14000? Plan doc lists individual OON 14000. Task family says once member reaches OOPM plan pays 100% for covered services for rest of year. Need decide OOPM thresholds: Individual in-network vs family in-network vs individual OON. Need how apply. For aggregate? Need track member OOP balance and family OOP balance. If member's OOP reaches individual in-network 7000? For in-network services, after member reaches OOPM, plan pays 100% for covered in-network services. But OON services? Individual OON OOPM 14000. Also family in-network OOPM 14000. If family reaches family OOPM? Plan pays 100% of allowed for covered in-network services? Usually family OOP stops cost share for in-network services for all members. Need apply. OON not family OOPM? The addendum: family balances can go past family amounts; family amounts are in-network amounts. For OOP? It says out-of-network claims measured against OON individual thresholds only; family amounts, which are in-network amounts, do not limit an OON claim. Credits from OON accumulate to member/family balances. So OON claims use member OOPM 14000. For in-network claims use member OOPM 7000 and family OOPM 14000? The task family rule: OOPM ceiling on member cost share for plan year; once reached plan pays 100% of allowed for covered in-network services. It doesn't mention family OOPM, but doc has. Need apply. Also if family OOPM reached, plan pays 100% for covered in-network services? Likely yes. Need track ending family_oopm. There can be overaccumulation? Balances not capped? It says balances are running total and not capped at in-network amounts for deductible. For OOPM? "A balance is running total of deductible_applied (for deductible) or member_responsibility (for OOP balance). Because OON thresholds are higher, OON claims can carry a member's balance past the in-network individual amount, and family balances past family amounts; balances are not capped at in-network amounts." This refers deductible? It says balances are running total of deductible_applied or member_responsibility. "Because OON thresholds are higher, OON claims can carry a member's balance past the in-network individual amount, and family balances past family amounts; the balances are not capped at the in-network amounts." Need parse: For OOPM? The OOP balance member_responsibility. Could end > threshold? It says not capped at in-network amounts. For deductible, member balance can exceed 3200 due to OON? Under aggregate? It says family balances past family amounts. This applies accumulators; we should not cap deductible/OOP balances at threshold; member_responsibility for a claim can cause balance exceed threshold? But OOPM logic: Once reached, plan pays 100% remainder. If a claim crosses OOPM, member_responsibility capped at remaining OOPM (not whole allowed), but member OOP balance after claim may equal threshold (capped by claim payment? Usually cost share capped, OOP doesn't exceed threshold). But statement says balances not capped at in-network amounts because OON thresholds higher? Could mean deductible balances are not capped; OOP maybe if OON allowed can push OOP past in-network OOPM? But if plan pays 100% after OOPM, member doesn't get past threshold for covered services. However if member has separate in-network vs OON OOPM? If in-network OOPM 7000 and OON OOPM 14000: a member who already exceeded 7000 from OON? If OON threshold 14000 allows cost share up to 14000, member OOP balance can exceed 7000 (in-network threshold) while still paying OON coinsurance, so not capped. That matches. But for in-network OOPM, once balance reaches 7000, in-network claims no cost share. OON claims still can push beyond 7000 up to 14000. Thus member OOP balance can exceed in-network OOPM; ending_oopm_a maybe actual balance possibly >7000. Need track member OOPM status for in-network vs OON thresholds. Need careful with OON deductibles: member deductible balance can exceed family/in-network? Aggregate family threshold 6400, OON individual threshold 6400. Could exceed.
Need determine exact adjudication rules.
Deductible:
- For in-network under AGGREGATE: no coinsurance until total family deductible credits reach family amount. There is no individual deductible. Deductible_applied = min(allowed, family remainder) until family deductible met. But what about family remainder after OON credits? Does OON deductible credits count toward family aggregate deductible? It says in-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. Family total? The task family: member's own accumulator and family accumulator both move on every claim that generates cost share. Under aggregate structure no member reaches coinsurance until family amount is met. So yes OON deductible credits move family deductible total too. Thus family deductible = sum of member deductible credits? Need track. But OON claims use OON individual deductible threshold (6400) for that member, not family threshold? Let's read ACCUMULATORS: A claim's deductible_applied is lesser of allowed and room left under threshold that applies to it:
in-network ......... smaller of member's individual remainder and family remainder (embedded), or family remainder alone (aggregate);
out-of-network ..... OON individual remainder, measured against member's same single deductible balance.
This says for in-network aggregate use family remainder only (no individual). For out-of-network use OON individual remainder. It doesn't say family remainder used for OON. But credits from OON accumulate to member/family balances. So for OON deductible, we use individual OON deductible threshold 6400 against member deductible balance (which includes prior in-network and OON deductible credits). But if member has already paid in-network deductible credits under aggregate, those count toward OON deductible threshold? Yes single member deductible balance, measured against 6400 when service is OON. This is weird but follow. So if a member's deductible balance >=6400, OON deductible_applied=0; if <6400, can credit up to 6400. But family deductible aggregate also accumulates, maybe could be met before individual OON threshold.
For in-network, family deductible threshold 6400. But if family total includes OON deductible credits, yes. If family total >=6400 then deductible_applied=0. If <6400, apply remaining. What about member's in-network individual deductible threshold? Aggregate says no individual deductible; in-network use family remainder alone. So ending_deductible per member is not threshold but credit accumulator. It can exceed? If member has multiple claims, credits accumulate. We track.
Coinsurance:
- Once applicable threshold met? For in-network after family deductible satisfied, coinsurance 10% of allowed (after deductible portion? If claim partially deductible, deductible applied to some allowed, coinsurance on remainder). Under aggregate, if family deductible not met, member pays 100% allowed as deductible, no coinsurance? Need split: deductible_applied = min(allowed, family_remainder); member_responsibility = deductible_applied + coinsurance on (allowed - deductible_applied) once deductible threshold met? But if threshold not fully met by this claim (family_remainder < allowed), after applying remaining deductible, the remaining allowed is subject to 10% coinsurance. So yes. If family_remainder >= allowed, all deductible, no coinsurance. If family_remainder =0, all coinsurance (subject to OOPM). For OON: threshold is individual OON deductible 6400. Once member's deductible balance >=6400, coinsurance 40% member/60% plan on remainder. But family deductible doesn't matter for OON coinsurance? Task says OON claims measured against OON individual thresholds only; family amounts do not limit OON claim. However "aggregate structure no member reaches coinsurance until family amount is met" could conflict. OON individual threshold applies. For OON, deductible_applied based on member OON remainder. If member OON deductible met (>=6400), coinsurance 40% of allowed, regardless family. Does "no member reaches coinsurance until family amount is met" apply only in-network aggregate? Plan says structure AGGREGATE—plan pays no coinsurance for any member until total family credits reach family deductible amount. But OON individual deductible 6400? It says OON claims measured against OON individual thresholds only; family amounts, which are in-network amounts, do not limit an OON claim. So for OON after individual OON deductible threshold met, coinsurance. Good.
OOPM:
- Need apply to member/family cost-share. Need order? For each claim, determine cost-share (deductible + coinsurance) then cap by OOPM? But multiple thresholds: member in-network OOPM 7000, member OON OOPM 14000, family in-network OOPM 14000. OON claims use OON individual threshold only. In-network claims likely if member's OOP balance >=7000 or family >=14000, no cost share for in-network services. But if a member OOP balance >7000 due to OON but family <14000, in-network services should be 100% plan? Once member reaches individual in-network OOPM, plan pays 100% for covered in-network services. So yes, member OOP balance >7000 blocks in-network cost share. But OON claims still use 14000. For family OOPM threshold, once family reaches 14000, plan pays 100% for covered in-network services for all members. For OON, family amount does not limit. But family OOP balance can exceed 14000 due to OON? It says balances not capped. But if family OOP >14000, in-network no cost share.
What about family OOPM and individual OOPM order? Member_responsibility should be capped at lower of remaining individual and family OOPM thresholds for in-network? Need if claim would exceed OOPM, cap cost share to remaining room. But member/family accumulators after capped by allowed. For OON, cap member OOP at 14000? But OON cost-share maybe deductible+coins; if member OOP remaining < costshare, cap member_responsibility? However family OOP may increase same amount, but family not limit OON. Need track.
Potential ambiguity: OOPM for aggregate family with OON? Could family in-network OOPM 14000 apply to all OON claims? It says individual (out-of-network) 14000. OON claims are measured against OON individual thresholds only; family amounts in-network do not limit. So no family cap on OON.
Need process 25 lines. Need decide preventive immunization. Let's simulate maybe both. Need final JSON. Let's thoroughly compute.
Ledger:
Line 1 Claim1 A in-network pharmacy allowed 74.87. Aggregate family deductible balance 0, family remainder 6400. Deductible_applied = 74.87. Family deductible=74.87, member A deductible=74.87. Costshare =74.87 (no coins). Member OOP=74.87, family OOP=74.87. Plan=0.
Line2 Claim2 C OON inpatient allowed 10883.95. OON individual deductible threshold for C: 6400. Member C deductible balance 0, remainder 6400. Deductible_applied = 6400. Remaining allowed=4483.95. Coinsurance after OON deductible: 40% = 1793.58 (10883.95-6400=4483.95*0.4=1793.58). But check OON deductible may be applied first; after deductible threshold met, plan pays? Yes. Member_responsibility =6400+1793.58=8193.58. Plan_paid =10883.95 -8193.58=2690.37 (60% remaining). Need OOPM: individual OON threshold 14000. C OOP 0, remaining 14000, costshare 8193.58 less. Family OOP? Aggregate? Does OON costshare add to family OOP? Task says family balances move every claim generating cost share. Yes family OOP =74.87+8193.58=8268.45. Family deductible =74.87+6400=6474.87. This exceeds family in-network deductible 6400 by 74.87. But deductible balances not capped. C [empty response]Grader detail
json{
"reason": "response did not contain parseable JSON"
}Reasoning · 30,000 tokens
We need solve this carefully. We need produce final JSON only. Need process ledger with plan document aggregate HDHP. Need compute components for claims 19,20 adjusted,25 and ending accumulators. Let's analyze step-by-step.
We need understand rules. Plan: Trinity HDHP 3200. Plan year 2026. Deductibles: in-network individual 3200, family 6400. Structure AGGREGATE — plan pays no coinsurance until total family credits reach family deductible amount. There is no individual deductible under this structure. OON individual deductible 6400. In-network and OON deductible credits accumulate to a SINGLE member deductible balance. The amount above is threshold measured when service is out-of-network. Wait "the amount above is the threshold that balance is measured against when the service is out-of-network." OON individual 6400? Yes. Family amounts in-network do not limit OON claims. OON claims measured against OON individual thresholds only; family amounts do not limit OON. But credits accumulate to member/family.
OOPM: individual in-network 7000, family in-network 14000, individual OON 14000. Once member reaches OOPM plan pays 100% of allowed for covered services for remainder of plan year. This plan no copays.
Preventive: in-network preventive no cost share. Out-of-network preventive subject to OON deductible and coinsurance. Need classify services.
Claims in ledger:
1 Claim1 A generic retail pharmacy fill IN. Allowed 74.87.
2 Claim2 C inpatient admission OON allowed 10883.95.
3 Claim3 C diagnostic lab panel OON allowed 967.99. Later void line14.
4 Claim4 A urgent care IN allowed 255.34.
5 Claim5 A ED IN allowed 3545.18.
6 Claim6 A allergy testing IN allowed 911.89. Later void line16.
7 Claim7 B ambulatory surgery IN allowed 7845.50.
8 Claim8 D ambulatory surgery IN allowed 6750.63.
9 Claim9 B inpatient admission IN allowed 12250.27.
10 Claim10 D inpatient admission IN allowed 12224.51.
11 Claim11 D annual wellness visit OON allowed 664.62. Is annual wellness visit preventive? Yes? In OON preventive subject OON deductible/coinsurance. Need classify.
12 Claim12 B generic retail pharmacy fill OON allowed 30.19.
13 Claim13 D screening colonoscopy, no polyp removed, OON allowed 716.51. Preventive screening? yes OON preventive subject OON deductible and coinsurance.
14 VOID Claim3: remove credits it generated from member C and family accumulators; post nothing. Not reprocess intervening claims.
15 Claim15 A outpatient endoscopy OON allowed 2331.25.
16 VOID Claim6: remove credits of claim 6 (A IN allowed 911.89) from accumulators; post nothing.
17 Claim17 E physical therapy course OON allowed 1373.69.
18 Claim18 C diagnostic lab panel OON allowed 593.21.
19 Claim19 B urgent care visit IN allowed 220.46.
20 Claim20 A routine immunisation IN allowed 1243.12. Adjusted line23 corrected allowed 745.87. Need final components after adjustment.
21 Claim21 C ED IN allowed 3516.29.
22 Claim22 E inpatient admission IN allowed 12475.02.
23 ADJUSTMENT Claim20: unwind original credits and re-adjudicate corrected allowed against accumulators as they stand at adjustment (after lines 1-22). Need compute original claim20 and adjustment.
24 Claim24 D PCP office visit IN allowed 201.22.
25 Claim25 D physical therapy course IN allowed 1508.35.
Need final accumulators. Important: deductible_applied is lesser of allowed amount and room under threshold applicable. Aggregate: for in-network claims, threshold family remainder; once family deductible reached, deductible_applied 0, all cost share coinsurance until OOPM. For OON claims, threshold OON individual remainder measured against member's single deductible balance. But what about in-network claims before family deductible? Aggregate says no member reaches coinsurance until family amount met, but deductible_applied under in-network uses family remainder alone. Member deductible accumulators? There are ending_deductible_a etc. They probably track member deductible credits (balances) even if aggregate threshold is family? Yes: "in-network and OON deductible credits accumulate to a SINGLE member deductible balance. The amount above is threshold ... when service OON." Ending_deductible per member likely accumulated deductible credits by member, family total sum. Under aggregate, in-network claims still credit family deductible and member's deductible? It says credits generate to member and family. The plan pays no coinsurance until total family credits reach family deductible. There is no individual deductible under aggregate. But accumulators requested ending_deductible_a etc probably member deductible balance; can exceed thresholds? Need compute from each claim's deductible_applied.
OOPM balances: member responsibility totals by member, family sum. Once member reaches OOPM? Need OOPM thresholds: individual in-network 7000, family in-network 14000, individual OON 14000. Rule: Once a member reaches the OOPM the plan pays 100% allowed for covered services. Need how aggregate interacts with OON OOPM? Need careful.
Plan document:
- OOPM: Individual (in-network) 7000; Family (in-network) 14000; Individual (out-of-network) 14000.
- Once a member reaches OOPM the plan pays 100% for covered services for remainder.
Does family OOPM apply? Likely aggregate family in-network? It says family total OOPM. Need track family OOPM and individual OOPM, maybe once member individual OOPM reached no member cost share for services? Need consider OON individual 14000. The OON coinsurance after deductible is 40% member. If member's OON OOP balance reaches 14000, plan pays 100% for OON? Maybe also all covered services? It says once a member reaches the out-of-pocket maximum the plan pays 100% of allowed amount for covered services for remainder. There are separate OOPMs (in-network vs OON), likely member OOP balance threshold depends on network? We need infer.
Also "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." So member and family OOP balances accumulate member responsibility regardless network? Out-of-network thresholds are higher, balances not capped. For OON claims measured against OON individual thresholds only; family amounts do not limit OON claim. For deductible: OON claim room = OON individual remainder. For OOPM: likely OON claim room measured against individual OON OOPM remainder? Family OOPM maybe doesn't limit OON? But "family amounts, which are in-network amounts, do not limit an out-of-network claim" specifically says for deductible. Probably applies to OOPM? It says family amounts (in-network amounts) do not limit an OON claim. So OON claims not capped by family in-network OOPM, but individual OON OOPM maybe yes. Once member reaches OOPM? Maybe individual OOPM threshold relevant to service? For IN services individual in-network OOPM 7000; family in-network 14000? Need aggregate? For OON services individual OON OOPM 14000.
Need model carefully: Each line updates accumulators. For each claim determine if preventive.
Generic retail pharmacy fill: not preventive? Routine prescription fill? Not listed preventive. Plan says every covered service, including office visits, emergency, retail pharmacy subject to deductible and coinsurance. So claim1 has cost share.
Inpatient: not preventive.
Diagnostic lab: not preventive.
Urgent care: not preventive.
Emergency department: not preventive.
Allergy testing: not preventive? Diagnostic not preventive.
Ambulatory surgery: not.
Annual wellness visit: preventive? Usually annual wellness is preventive. But OON preventive subject OON deductible/coinsurance. If in-network would no cost share. It's OON line11. Need process as preventive OON? Yes.
Generic retail pharmacy OON: not preventive.
Screening colonoscopy no polyp removed: preventive OON.
Outpatient endoscopy: not preventive (diagnostic? outpatient endoscopy; probably not preventive).
Physical therapy: not preventive.
Urgent care: not.
Routine immunisation: preventive. In-network. If preventive in-network no cost share, moves no accumulator. But line20 allowed adjusted; if preventive, no cost share both original and adjusted; adjustment likely zero credits? Need see: "Preventive services in-network carry no cost share and move no accumulator." Outpatient? Routine immunization likely preventive. In-network. So original Claim20 likely 0 member, 0 deductible, 0 coinsurance. Adjustment no change? Need maybe if adjustment correct allowed downward still 0. Need final components for Claim20: 0.00. But wait line20 before adjustment: routine immunisation in-network: preventive no cost share. Yes.
But perhaps routine immunization is preventive? Yes. If not preventive? It is a covered service, deductible/coinsurance. But plan preventive care says in-network preventive required to be covered without cost share. "Routine immunisation" is typically preventive. Need classify? likely yes. Need check: "annual wellness visit" and "screening colonoscopy" and "routine immunisation" are preventive. Good.
Now need process accumulators. Need handle aggregate deductible. Let's define:
- Each member has member deductible balance (sum of deductible_applied generated by their claims, both IN and OON? yes single balance). Also member OOP balance (sum member_responsibility). Family total deductible balance = sum of member deductible credits? Under aggregate, family total threshold 6400. But OON claims measured against individual OON threshold (6400) only; family amounts don't limit OON. However family deductible accumulates from all claims? Need yes "credits ... still accumulate to member's balance and family balance." For in-network claim deductible_applied is family remainder (aggregate), not min member remainder (there is no individual). For OON claim deductible_applied is lesser of allowed and (OON individual threshold - member's deductible balance). But family deductible also gets that credit. Does an in-network claim's deductible_applied capped by family remainder, but if member balance exceeds 6400 due to OON credits, that doesn't matter. Need yes.
OOP: For in-network claims, member cost share capped by member individual IN OOPM? Family IN OOPM? Aggregate? Need think: OOPM: Individual (in-network) 7000; Family (in-network) 14000. Once a member reaches the OOPM the plan pays 100% for covered services. Does family OOPM affect? It might be aggregate: once family total reaches 14000, plan pays 100% for all covered in-network services? But wording individual: Once a member reaches the OOPM. Family OOPM likely family total, once reached no member cost share for remaining family? In typical family deductible/OOPM aggregate: after family deductible reached, coinsurance until family OOP reached. The task asks ending_family_oopm. Likely need consider family OOP maximum. For in-network claims, room for member responsibility is limited by both member individual IN OOPM and family IN OOPM? Also OON individual OOPM maybe separate? Need inspect plan: "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 family OOPM, but lists family amount. In family plan, family OOPM is ceiling for total family cost share; once reached plan pays 100 for covered services for all members? The glossary: OOPM: ceiling on member cost share for plan year. Once reached, plan pays 100% of allowed for covered in-network services. So likely family total OOPM stops family in-network cost share once reached. Individual OOPM stops member cost share for that member (for network? maybe in-network). But need implement.
There is ambiguity on how OOPM caps apply per line. Need deduce from examples and language. "A balance is the running total ... member_responsibility (for an out-of-pocket balance)." Because balances not capped at in-network amounts due to OON thresholds higher. "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." For deductible. This suggests for OOPM too? The OON individual threshold maybe 14000, family amounts 14000? But family in-network OOPM 14000, individual OON OOPM 14000 equal. Need know OON claims room under member OOP balance. If member's OOP balance exceeds IN OOPM due to OON claims, IN OOPM doesn't necessarily cap OON until OON OOPM. Need model: each claim's network determines which OOPM threshold applies to limit member responsibility: IN: individual IN OOPM 7000 and family IN OOPM? maybe yes. OON: individual OON OOPM 14000? family doesn't limit. Then after OON credits push member balance above 7000, future IN claims still capped by individual IN OOPM? If member's IN OOPM balance is running total of all member responsibility? It says individual OOP balance? "A balance is running total ... member_responsibility (for an out-of-pocket balance)." No distinction by network. But separate thresholds: individual in-network, family in-network, individual out-of-network. How combine? Could be same OOP balance measured against threshold based on service network: if claim is in-network, member's OOP balance cannot exceed individual IN OOPM; if out-of-network, cannot exceed individual OON OOPM. Family OOP balance measured against family IN OOPM for in-network claims. That seems plausible: same balances, different thresholds depending on service. But if a member already has OON OOP balance 14000, future in-network claim would be capped at 7000 and plan pays 100? If balance > 7000, no IN cost share. If member balance below 7000, IN claim can cost share up to 7000. This matches "Once a member reaches the OOPM" if threshold for claim's network? Need decide.
Alternative: Separate balances per network? They don't request separate, ending_oopm_a total member responsibility. So use single balance, multiple thresholds.
Need process all lines with exact arithmetic. Let's set initial:
Members A-E deductible credits: 0.
Family deductible total 0.
Member OOP: 0, family OOP: 0.
Family deductible threshold aggregate: 6400. For IN claims: if fam_deduct_total >= 6400, ded_applied=0; else ded_applied = min(allowed, 6400 - fam_deduct_total). For OON claims: if member_ded_total >= 6400? OON threshold 6400; else min(allowed, 6400 - member_ded_total). Does aggregate family deductible affect OON? No, family amounts do not limit OON. So OON deductible applies if member's deductible balance below 6400, even if family already reached 6400. But wait plan says "plan pays no coinsurance for any member until total family credits reach the family deductible amount." That seems all services? But addendum says OON measured against OON individual thresholds only; family amounts do not limit OON. Could there be conflict? OON threshold individual 6400; family amount is 6400 too. The aggregate structure says no coinsurance until total family credits reach family deductible. If OON claim happens before family total 6400, can member have deductible_applied? Yes: OON deductible room measured against OON individual remainder, not family. If OON deduct credits contribute to family total, once family total 6400, IN coinsurance starts. But if family total not reached and OON individual 6400 not reached, OON member may pay deductible. The statement "no coinsurance until total family credits reach family deductible amount" applies to coinsurance, not necessarily deductible. For OON, coinsurance after OON individual deductible? Yes OON deductible threshold individual 6400. Family not limit. So OON coinsurance can begin even if family total hasn't reached 6400? Need if "plan pays no coinsurance for any member until total family credits reach family deductible" might block coinsurance on OON if family total not met. But addendum says OON claims measured against OON individual thresholds only; family amounts do not limit an OON claim. It says "Once applicable threshold met, deductible_applied 0..." For OON, applicable threshold is OON individual. Then coinsurance applies? likely yes. The family aggregate condition maybe for in-network deductible threshold; but "no coinsurance for any member until total family credits" seems absolute. Hmm need parse.
The plan document aggregate: "Structure ........................ AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." Then OON: "Out-of-network (individual) 6400. 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 seems to create individual OON deductible even under aggregate? Yes because OON threshold measured against member's single deductible balance. "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." So OON coinsurance starts once member's OON deductible balance 6400, independent of family total. The earlier "no coinsurance until total family credits" likely refers in-network aggregate deductible; OON separate thresholds override. Good.
Need process all lines with voids adjustments.
Let's compute step-by-step. Need consider OOPM caps. Let's create formal adjudication function for each claim.
Given claim allowed, network, member.
Deductible:
If service in-network preventive: no cost share; ded=0, mr=0, plan=allowed. No OOP movement. Does adjustment? no.
If service OON preventive: subject to OON deductible and coinsurance. Not no cost share.
If not preventive:
- If network IN:
family_ded_remaining = max(0, 6400 - family_deduct_total). Since aggregate no member individual for deductible. But is family_deduct_total capped? no.
ded_applied = min(allowed, family_ded_remaining). This ded applies to member's deductible balance? Under aggregate, even though no individual deductible threshold, deduct credits by member accumulate. Yes.
after_deductible = allowed - ded_applied.
If family_ded_remaining was 0? (family total >=6400) then coinsurance applies. But what if family_ded_remaining > 0 and after_deductible >0? For aggregate, no coinsurance until family credits reach family amount, meaning if allowed amount exceeds family remainder, after satisfying family deductible with part, does the remainder switch to coinsurance in same claim? Typically deductible and coinsurance same claim: pay ded up to threshold, coinsurance on rest once threshold met. Does "plan pays no coinsurance until total family credits reach family deductible amount" allow coinsurance on remaining allowed of the same claim after reaching threshold mid-claim? Yes likely. Ded_applied is room, then coinsurance on rest. So if family_ded_remaining < allowed, after ded = allowed - room, coinsurance starts. Good.
- If network OON:
member_ded_remaining = max(0, 6400 - member_deduct_total). ded_applied = min(allowed, member_ded_remaining). after = allowed - ded_applied. OON coinsurance 40/60 if ded threshold met (ded_applied allowed? or member_ded_remaining 0? If ded_applied < allowed, coinsurance on rest after meeting threshold). If member_ded_remaining was 0 initially, all after coinsurance.
Coinsurance:
IN: 10% member on after amount if deductible threshold met. But aggregate: if family deductible not met? If ded_applied consumed family remainder (so after allowed may be 0 if allowed <= remaining; if allowed > remaining, threshold met, coinsurance on rest). If allowed <= remaining, member pays allowed as deductible, no coinsurance. Good.
OON: 40% member on after if member OON deductible threshold met. If allowed <= member_ded_remaining, all deductible, no coinsurance.
OOPM caps:
Need cap member responsibility. Need determine exact logic: For each claim, member[empty response]Grader detail
json{
"reason": "response did not contain parseable JSON"
}33GPT-5.6 Luna · OpenAI27.9s · 3,046 out | 44.1s · 4,442 out | 20.8s · 2,347 out
Reasoning · 2,647 tokens
**Clarifying out-of-network claims**
It seems like the family out-of-pocket maximum (OOPM) doesn't restrict out-of-network (OON) claims. Instead, OON claims would consider individual thresholds. If the family's OOPM is more than 14,000 due to OON claims, further in-network claims after that point might be covered at 100%. Also, it looks like the family balance continues to accumulate even beyond that OOPM, and I need to carefully apply this understanding to later claims based on the family's OOP accumulator.
**Evaluating JSON numeric formats**
I'm thinking through whether to use strings for financial amounts. The instruction asks for "plain number with two decimal places," implying that JSON numeric types like 220.46 or 0.00 might be necessary. But if we're dealing with some values like gold, they could be strings to ensure the two-decimal format stays intact. I wonder if we need to confirm how out-of-pocket maximums apply to individuals or families. It feels a bit complex!json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8043.66,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3278.64,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 17909.13
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8043.66,
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3278.64,
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 17909.13,
"ok": true,
"present": true
}
],
"fabricated": true,
"abstained": false
}Reasoning · 4,043 tokens
**Evaluating OOP maximums**
I’m working on understanding the OOP (out-of-pocket) maximums here. For instance, the family OOP might reach 14k, but how does wording like "Once a member reaches OOP maximum" apply? I need to clarify if it means family coverage pays 100% after reaching that threshold. The plan says individual 7000 and family 14000, but I wonder about the nuances of these rules. Should I interpret these accumulations based on the line items provided?
**Assessing OOP maximums and balances**
I'm considering how to handle deductible balances that exceed family amounts, but OOP has no such caveat. So, I likely need to cap responsibility at the family OOP max. I see a family OOP total before line 13 at 13728.79; if claim 13 is 716.51, that would push it to 14445.30. I’m wondering if once the family OOP maximum is reached, all future claims are 100% covered. The wording could imply different thresholds for individuals versus families, and I definitely need to clarify that!
**Calculating family deductible sum**
I’m trying to find the total of the family deductible by adding several amounts together. It looks like I've got A for 2406.12, B for 30.19, C totaling 6400, D at 1381.13, and E at 1373.69. So, I need to add all those up. I’ll make sure to double-check my calculations for accuracy as I go along! I want to get this right for the user.json{
"claim_19_member_responsibility": "0.00",
"claim_19_plan_paid": "220.46",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "0.00",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "0.00",
"claim_25_plan_paid": "1508.35",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "0.00",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2039.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8430.86",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3278.64",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "17909.13"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "220.46",
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1508.35",
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2039.77",
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8430.86",
"ok": true,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3278.64",
"ok": true,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "17909.13",
"ok": true,
"present": true
}
],
"fabricated": false,
"abstained": false
}json{
"claim_19_member_responsibility": "22.05",
"claim_19_plan_paid": "198.41",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "22.05",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "150.84",
"claim_25_plan_paid": "1357.51",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "150.84",
"ending_deductible_a": "2406.12",
"ending_oopm_a": "2786.17",
"ending_deductible_b": "30.19",
"ending_oopm_b": "2061.82",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "8782.49",
"ending_deductible_d": "1381.13",
"ending_oopm_d": "3449.60",
"ending_deductible_e": "1373.69",
"ending_oopm_e": "2621.19",
"ending_family_deductible": "11591.13",
"ending_family_oopm": "19701.27"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "22.05",
"ok": false,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "198.41",
"ok": false,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "22.05",
"ok": false,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "150.84",
"ok": false,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1357.51",
"ok": false,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "150.84",
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "2406.12",
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2786.17",
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "30.19",
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2061.82",
"ok": false,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "8782.49",
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "1381.13",
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3449.60",
"ok": false,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "2621.19",
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "11591.13",
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "19701.27",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}0Kimi K2.6 · Moonshot571.0s · 30,000 out | 331.1s · 30,000 out | 278.8s · 30,000 out
Reasoning · 30,000 tokens
We need to process the ledger line by line, keep track of accumulators (deductible and OOPM) for each member and family. The plan is an HDHP with aggregate deductible in-network, no individual deductible. Family deductible in-network = 6400. Individual in-network OOPM = 7000, family in-network OOPM = 14000. Out-of-network individual deductible = 6400, out-of-network individual OOPM = 14000. There are no copays. Cost share: after deductible, in-network coinsurance 10% member / 90% plan; out-of-network 40% member / 60% plan. Preventive in-network has no cost share. Out-of-network preventive is subject to OON deductible and coinsurance. There is a 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 each member has a single deductible balance that counts toward both INN and OON thresholds? Wait, need to parse.
Plan doc 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 each member has one running deductible balance. For in-network claims under aggregate structure, the deductible applied is measured against the family remainder (since no individual deductible). For out-of-network claims, the deductible applied is measured against the out-of-network individual remainder (6400) measured against the member's same single deductible balance. So the member's single deductible balance is the sum of deductible_applied from both INN and OON claims. For INN claims, the threshold is family deductible (6400) aggregate: plan pays no coinsurance for any member until total family credits reach 6400. So the family deductible balance is the sum of all deductible_applied across all members. For OON claims, the threshold is the OON individual deductible (6400) per member, using the same single member balance.
But wait: The family deductible is aggregate: "the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." So for INN claims, we track family deductible balance. The amount applied to deductible for an INN claim is the lesser of allowed amount and family remainder (6400 - family_deductible_balance_sofar). Since there is no individual deductible, the member's own deductible balance for INN is not directly relevant? But the document also says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." That implies each member's deductible balance is increased by the deductible_applied of their claims, regardless of network. And family deductible balance is the sum of all members' deductible balances? Or perhaps the family balance is just a separate sum.
Let's parse the ACCUMULATORS addendum carefully:
"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);
out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance.
Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible.
A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts.
Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
Wait: The addendum says for in-network: "the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate)". Since the plan is aggregate, we use the family remainder alone for in-network. However, the member still has a "single deductible balance" that accumulates both INN and OON credits. The family deductible balance is the sum of members' balances? Or a separate family total? The prompt says "Family total deductible ..." as a separate accumulator. The family total OOPM ... separate.
The addendum: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
So there is a family balance that gets increased by OON claims too? That seems odd because family deductible is an in-network concept. But the addendum explicitly says OON credits accumulate to the family balance. So the family deductible balance is the total of all deductible_applied across all members and all claims (both INN and OON). However, for INN claims, the limit on deductible_applied is the family remainder (6400 - family_deductible_balance). For OON claims, the limit on deductible_applied is the member's OON individual remainder (6400 - member_deductible_balance). But the member's deductible balance is the same single balance used for both. So if a member has OON claims that apply to deductible, that increases their single balance, which reduces their OON remainder. It also increases the family balance.
But wait: The addendum says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." That means each member has one balance. So if a member has an INN claim that applies $100 to deductible, their member balance goes up by $100. If they later have an OON claim, the OON remainder is measured against 6400 minus that same balance (including the INN $100). Also, the family balance is increased by that $100.
But under aggregate structure, for INN claims, the deductible_applied is limited by the family remainder, not the member's individual remainder. However, the member's balance is still incremented by that amount? The addendum says for in-network aggregate: "the family remainder alone". So the deductible_applied is the lesser of allowed amount and family remainder. The member's individual remainder under aggregate is irrelevant for INN. But the member's balance is still increased by that amount. Does that mean the member's balance can exceed the individual in-network threshold (3200) and even the family threshold? The addendum says balances are not capped. So yes.
Let's re-read: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
So family balance is a running total of family deductible_applied. It can exceed 6400. But once it reaches 6400, INN claims will have deductible_applied = 0 (because family remainder is 0). However, OON claims can still have deductible_applied if the member's OON remainder > 0. And that will increase the member's balance and the family balance beyond 6400.
Similarly, OOPM: There is individual OOPM (7000 INN, 14000 OON) and family OOPM (14000 INN). The addendum doesn't explicitly describe OOPM calculations, but standard rules: Member cost share (deductible + coinsurance + copay) counts toward OOPM. Since no copays, it's deductible_applied + coinsurance_amount. Once a member reaches their individual OOPM, plan pays 100% of allowed amount for covered services for the remainder of the plan year. For INN services, the relevant OOPM is the individual in-network OOPM (7000) or family OOPM (14000)? The plan doc 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 individual vs family. But there are individual and family OOPM listed. Usually, under family coverage, the family OOPM is an aggregate, and the individual OOPM is embedded (i.e., if a member hits 7000, they are done even if family hasn't hit 14000). The plan doc says: "Out-of-pocket maximum: Individual (in-network) 7000. Family (in-network) 14000. Individual (out-of-network) 14000. 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 embedded vs aggregate for OOPM. Usually OOPM is embedded (individual OOPM works for each member). But the prompt doesn't say aggregate or embedded for OOPM. It only says the deductible structure is aggregate. For OOPM, typically it's embedded (individual caps apply). We need to infer from the glossary and rules.
The glossary says:
- Out-of-pocket maximum (OOPM): the ceiling on member cost share for the plan year. Once reached, the plan pays 100% of the allowed amount for covered in-network services. Premiums and non-covered services never count toward it.
No mention of embedded vs aggregate for OOPM.
The plan doc lists individual and family OOPM. Since the deductible is explicitly stated as aggregate, but OOPM is not given a structure, I think we assume the standard embedded structure: each member has their own individual OOPM, and the family OOPM is a cap for the whole family. Usually, under an embedded family OOPM, once any member hits the individual OOPM, they are done; once the family total hits the family OOPM, all members are done even if none hit individual. But the plan doc doesn't specify. However, 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 suggests individual OOPM is the trigger for a member. Family OOPM might be a separate cap. In many plans, the family OOPM is just the sum, but the individual OOPM is embedded. We need to decide how to handle OOPM accumulation.
But looking at the accumulators section: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." So the member's OOP balance is the running total of member_responsibility. The family OOP balance is the running total of all members' member_responsibility? Likely yes. The addendum says OON credits accumulate to the member's balance and to the family balance. That applies to deductible balances. For OOP, it probably also accumulates to both. So family OOPM is the sum of all member OOP responsibilities.
But the plan doc says for OOPM: "Individual (in-network) 7000. Family (in-network) 14000. Individual (out-of-network) 14000." Since OON individual OOPM is 14000, and INN individual is 7000. What about OON family? Not listed. Usually, the family OOPM applies to INN only, but OON claims still count toward the individual OON OOPM and also toward the family OOPM? The plan doc doesn't say OON family OOPM. It 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." Which OOPM? There are two individual amounts: 7000 for INN and 14000 for OON. Perhaps the member has separate INN and OON OOP balances? Or a single OOP balance measured against different thresholds depending on network? The plan doc doesn't explicitly say they are separate balances. But the deductible section explicitly says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." That implies that OOP might also be a single balance? But it lists separate thresholds. Let's read carefully.
Plan doc:
Out-of-pocket maximum
Individual (in-network) ................ 7000.00
Family (in-network) .................... 14000.00
Individual (out-of-network) ............ 14000.00
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.
There's no mention of a single balance for OOP. The only "single balance" mentioned is for deductible. For OOP, the natural reading is that the member's cost share counts toward both the individual OOPM and the family OOPM. But which threshold applies to stop cost sharing? Usually, in-network services count toward the in-network OOPM, and out-of-network services count toward the out-of-network OOPM. But the plan doc says "Once a member reaches the out-of-pocket maximum..." singular. It might mean whichever is applicable: if they have INN services, they stop paying when they hit 7000 INN individual (or 14000 family). If they have OON services, they stop when they hit 14000 OON individual. But what if they mix? Does cost share from INN count toward the OON individual OOPM? Typically no, but some plans combine them. The plan doc is ambiguous.
However, the addendum for accumulators only talks about deductible balances. It says: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." This suggests there is a single out-of-pocket balance per member (running total of member_responsibility). And presumably a family out-of-pocket balance (running total of all member_responsibility). But then which threshold is used to determine when the member stops paying? The plan doc lists three thresholds: individual INN (7000), family INN (14000), individual OON (14000). If the member has a single OOP balance, then for INN services, we check if the balance has reached 7000 (individual) or 14000 (family). For OON services, we check if the balance has reached 14000 (individual OON). But the family OOPM is "in-network". Does it cap OON cost share? Usually, family OOPM is a separate accumulator that includes all cost share, but the plan doc doesn't clarify.
Let's think about typical HDHP rules. In many HDHPs, the deductible and OOPM are combined across INN and OON for HSA-qualified plans? Actually, for HSA-qualified HDHPs, the IRS requires that the plan have a minimum deductible and a maximum out-of-pocket. In-network and out-of-network may be combined or separate. But this is synthetic.
Given the addendum: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." This specifically refers to deductible thresholds. It says family amounts (which are in-network amounts) do not limit an out-of-network claim. For OOPM, there is no analogous statement. But perhaps the same logic applies: OON claims are measured against OON individual OOPM only; family OOPM (which is INN) does not limit an OON claim. However, the plan doc doesn't say that. But the addendum's phrasing about "family amounts, which are in-network amounts" suggests that the family deductible and family OOPM are considered in-network only.
Wait, the addendum says: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." This is under the ACCUMULATORS section, which is about deductible. It doesn't mention OOPM. But the plan doc's OOPM section lists family (in-network). So likely the family OOPM is an in-network family cap. OON claims count toward the member's OON individual OOPM (14000) and also contribute to the family OOPM total, but the family OOPM doesn't stop OON cost sharing. However, the prompt doesn't ask us to stop OON cost sharing based on family OOPM. It asks for ending accumulators.
Actually, the key question is: when does a member stop paying cost share? 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." If a member reaches 7000 INN individual OOPM, then for INN services they pay 0. If they reach 14000 OON individual OOPM, then for OON services they pay 0. But what about the family OOPM? If the family reaches 14000 INN family OOPM, does that mean all members stop paying for INN services? Usually yes, in embedded family OOPM, the family cap is a second cap. But if it's not embedded, maybe the family OOPM is just a cap that applies to the whole family, meaning once total family OOP hits 14000, everyone stops paying INN cost share. The plan doc is silent on OOPM structure.
Given that the deductible is aggregate, perhaps the OOPM is also aggregate? But the plan doc didn't say "Structure: AGGREGATE" for OOPM. It only said that for deductible. For OOPM, it just lists amounts. In many plans, the OOPM is embedded even if the deductible is aggregate. But it's not specified. However, the family OOPM is exactly double the individual OOPM (7000/14000), which is typical for embedded family OOPM (two people). But the family deductible is also double the individual deductible (3200/6400). So that pattern doesn't resolve.
We need to see if any claims would be affected by OOPM caps. Let's compute the cost share for each claim and see if any member hits 7000 or 14000. That might tell us if OOPM matters for the final answer.
Let's process all claims step by step, carefully tracking accumulators. I'll set up a table.
Plan details:
- Deductible: Aggregate INN family = 6400. No individual INN deductible.
- OON individual deductible = 6400.
- Member single deductible balance: starts at 0 for each.
- Family deductible balance: starts at 0.
- OOPM: Individual INN = 7000. Family INN = 14000. OON Individual = 14000.
- We need to track member OOP balance (single? or separate INN/OON?). The prompt says "ending_oopm_a" etc. That suggests a single OOP balance per member and a family OOP balance. But which threshold is used to cap? The task says "ending_oopm_a" etc. The plan doc lists three thresholds. But the accumulator addendum says "A balance is the running total of ... member_responsibility (for an out-of-pocket balance)." It doesn't specify separate INN and OON OOP balances. So there is one OOP balance per member. But then there are multiple thresholds. How to apply?
Perhaps the OOP balance is compared against the relevant threshold based on the claim's network:
- For INN claims: the member stops paying once their individual INN OOPM (7000) is reached. The family stops paying once family INN OOPM (14000) is reached.
- For OON claims: the member stops paying once their individual OON OOPM (14000) is reached. The family OOPM doesn't cap OON.
But 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 "in-network" or "out-of-network". So if a member hits 7000 INN OOPM, they stop paying for all covered services? Or only INN? The phrase "covered services" includes both. But the OOPM table lists separate INN and OON individual amounts. That suggests the OOPM is network-specific: INN OOPM is 7000, OON OOPM is 14000. If a member hits 7000 from INN cost share, do they also stop paying for OON services? Typically no; they would still pay OON cost share until they hit the OON OOPM of 14000. But the plan doc doesn't explicitly say that. However, the existence of a separat[empty response]Grader detail
json{
"reason": "response did not contain parseable JSON"
}Reasoning · 30,000 tokens
We need to process ledger lines in order, compute accumulators (deductible and OOPM for each member and family), and then report final components for Claims 19, 20, 25, and ending accumulators for all members and family.
Plan details: Trinity HDHP 3200.
Plan year 2026.
Deductible:
- Individual in-network: 3200.00
- Family in-network: 6400.00
- Structure: AGGREGATE. "the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
Wait: The document says: "Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure."
Out-of-network deductible: individual 6400.00. No mention of family out-of-network deductible? The glossary/accumulator addendum: "in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate); out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."
But the plan document says there is no individual deductible under this structure (aggregate). Hmm. However the addendum says for in-network aggregate: "the family remainder alone (aggregate)". So under aggregate, the deductible_applied for in-network is the family remainder (i.e., the remaining family deductible). Since there is no individual deductible, we only track family deductible. However out-of-network uses the out-of-network individual remainder measured against the member's same single deductible balance.
Wait, the addendum says:
"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);
out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."
Since the plan is aggregate for in-network, there is no individual deductible. So the in-network deductible_applied is the family remainder alone. The out-of-network deductible_applied is the out-of-network individual remainder (6400.00) measured against the member's same single deductible balance.
Wait: "the member's same single deductible balance". That implies there is one deductible balance per member that accumulates credits from both in-network and out-of-network claims. The threshold that balance is measured against depends on whether the service is in-network or out-of-network. 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."
So each member has a single deductible balance (running total of deductible_applied). For in-network, the threshold is the family deductible (6400) because aggregate. For out-of-network, the threshold is the individual out-of-network deductible (6400). But the balance is the same single balance. Hmm, but the addendum says for out-of-network: "the out-of-network individual remainder, measured against the member's same single deductible balance." The remainder would be 6400 minus the member's current balance. For in-network aggregate: the family remainder (6400 minus family total balance) is the limit.
But wait: The plan document says "There is no individual deductible under this structure." But there is an out-of-network individual deductible amount listed: 6400.00. So for out-of-network, the individual threshold applies.
The family total deductible balance is the sum of all members' deductible balances? Or is it a separate family accumulator? The rules say: "Process lines in the order listed. Each line updates the accumulators the next line is measured against, for the member AND for the family." and "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: in-network ... the family remainder alone (aggregate); out-of-network ... the out-of-network individual remainder, measured against the member's same single deductible balance."
Also: "Once the applicable threshold is met, deductible_applied is 0.00... A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." It also says: "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." So family deductible balance accumulates all members' deductible credits.
Important: Under aggregate in-network, the family deductible must be satisfied in full before any member reaches coinsurance. So before family deductible is met, every in-network claim for any member has deductible_applied = min(allowed amount, family remainder). No coinsurance until family deductible is met.
After family deductible is met, in-network claims have deductible_applied = 0 and coinsurance applies (10% member, 90% plan), unless OOPM is reached.
For out-of-network claims: The deductible_applied is limited by the out-of-network individual remainder (6400 - member's balance). Once the member's balance reaches 6400 (out-of-network individual threshold), no more deductible applies for that member's out-of-network claims. Then coinsurance is 40% member / 60% plan. But note: the member's balance is the same balance used for in-network. However for in-network under aggregate, the threshold is family 6400. But the member's balance can be less than 6400 while family balance is less than 6400. If the family balance reaches 6400, then in-network claims for all members go to coinsurance, even if a particular member's balance is low. However out-of-network claims for a member with balance < 6400 might still be subject to deductible if the member's balance hasn't reached 6400? Wait, but if the family balance is 6400, the member's balance might be less than 6400 (e.g., only one member contributed). But out-of-network threshold is individual 6400. So that member could still have deductible room for out-of-network. But the family balance being 6400 means in-network is done. So the same balance is measured against different thresholds depending on network.
But hold on: 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." The "amount above" refers to the Out-of-network (individual) 6400.00. So the member's balance accumulates both in-network and out-of-network credits. The in-network threshold is the family deductible (6400) under aggregate. But the family balance is the sum of all members' balances? Or is there a separate family accumulator? The prompt says "Family total deductible ... Family total out-of-pocket". So yes, we need to track family totals.
The addendum: "An ADJUSTMENT line unwinds the named claim's credits from every accumulator they touched and re-adjudicates that claim at its corrected values against the accumulators as they stand at the adjustment." So when adjusting, we remove the claim's deductible_applied from the member's deductible balance and the family deductible balance, and remove member_responsibility from member's OOPM and family OOPM. Then re-adjudicate using current accumulators.
Also: "Preventive services in-network carry no cost share and move no accumulator. An out-of-network preventive service is subject to the out-of-network deductible and coinsurance."
The plan has no copays. So copay_amount is always 0.00.
We need to track for each member: deductible balance (accumulator), OOPM balance (accumulator). Family: deductible balance (sum of members? or separate?). The prompt gives family accumulators as separate values. We need to maintain them.
Important nuance: Under aggregate, there is no individual deductible. So the in-network deductible_applied is based solely on family remainder. But the member's balance still increases by the deductible_applied amount? The addendum says "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." This implies that every claim's deductible_applied adds to both the member's balance and the family balance. Even under aggregate, the member's deductible balance increases. But for in-network, the "room left under the deductible threshold" is the family remainder. So deductible_applied = min(allowed amount, family remainder). This is limited by the family remainder, not the member's individual remainder (since there is none). So if family remainder is 1000, a member's in-network claim of 500 applies 500 to family and member balances. Then next member's in-network claim: family remainder is 500, so deductible_applied = min(allowed, 500). So it is possible for one member to have a very high balance and others to have low balances, but the family total cannot exceed 6400. Once family total hits 6400, no more in-network deductible applies for anyone. But out-of-network claims still check the member's individual remainder against 6400. Since the member's balance might be less than 6400 (if they haven't had many claims), out-of-network deductible could still apply until that member's balance reaches 6400.
Wait, but if the family balance is 6400, the sum of all members' balances is 6400. Some members could have balances below 6400. For out-of-network, the threshold is 6400 per member. So a member with balance < 6400 still has out-of-network deductible room. But if family balance is 6400, in-network deductible is satisfied for all. So out-of-network claims for a member with balance <6400 would still have deductible. Is that correct? The addendum says "out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance." Yes. So that seems right.
Now OOPM: The plan says:
"Out-of-pocket maximum
Individual (in-network) ................ 7000.00
Family (in-network) .................... 14000.00
Individual (out-of-network) ............ 14000.00
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 OOPM accumulates member_responsibility (deductible_applied + coinsurance + copay). Since no copays, it's deductible_applied + coinsurance. However, the addendum says: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." So OOPM balance = sum of member_responsibility from previous claims.
Important: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts."
Also: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
So for OOPM:
- In-network: once a member's OOPM balance reaches 7000.00, that member pays 0 for in-network. The family OOPM is 14000.00. Does aggregate vs embedded matter for OOPM? The plan document doesn't say OOPM is aggregate. Usually family OOPM can be embedded or aggregate. The plan says "Family (in-network) .................... 14000.00". It doesn't specify structure for OOPM. The prompt says for deductible structure is aggregate. For OOPM, we need to infer. Typically, for HDHP with aggregate deductible, the OOPM may also be aggregate? Or it could be embedded. The plan document does not specify the OOPM structure. However the glossary says "Embedded deductible: an individual deductible inside a family deductible; the individual amount can be satisfied on its own. Aggregate deductible: the family amount must be satisfied in full before the plan pays for any member." The plan only says structure is AGGREGATE for deductible. It doesn't say OOPM structure. We need to see if the OOPM is aggregate or embedded.
The prompt's family accumulator section lists "Family total out-of-pocket". The addendum says "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim." This refers to OOPM? "the family amounts, which are in-network amounts" could refer to both deductible and OOPM. The family OOPM is an in-network amount. The out-of-network OOPM individual is 14000, same as family in-network. Hmm.
Wait: The family OOPM is 14000. The out-of-network individual OOPM is also 14000. So they are equal. This may simplify.
But for in-network OOPM, do we need to check individual OOPM (7000) per member or family OOPM (14000) before the plan pays 100%? 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." This suggests the individual OOPM is what matters for a member. But family OOPM also exists. Usually, with embedded OOPM, once a member hits individual OOPM, they are done; once family hits family OOPM, all members are done. With aggregate OOPM, the family amount must be met before any member gets 100% coverage (but that would be unusual; typically OOPM is embedded even if deductible is aggregate for HDHP HSA-compatible plans? Actually HSA-compatible plans must have aggregate deductible but can have embedded OOPM or aggregate OOPM. The ACA requires embedded OOPM for non-grandfathered plans? Wait, for family coverage, the OOPM cannot exceed the individual OOPM for any member under ACA? Actually ACA requires that the family OOPM not exceed the individual OOPM? No, ACA requires that for family coverage, the individual OOPM cannot exceed the individual limit, but the family OOPM can be higher. However there are rules about embedded vs aggregate OOPM. But the prompt's plan document doesn't specify OOPM structure. We need to deduce from the material.
The addendum says: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: in-network ... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate); out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance."
It specifically describes deductible thresholds. It does not describe OOPM thresholds. For OOPM, the plan says "Once a member reaches the out-of-pocket maximum the plan pays 100%..." So the trigger is the member reaching the OOPM. That suggests the individual OOPM is the threshold for each member. But the family OOPM might be a cap on the family's total? The plan says "Family (in-network) .................... 14000.00". If a member reaches 7000, they are done. The family total could go up to 14000. If the family total reaches 14000 before any other member reaches 7000, does that mean all members are done? The plan document doesn't say. But the prompt asks for ending_family_oopm. So we must track family OOPM.
In many plans, the family OOPM is a separate limit: once the sum of all members' OOPM reaches the family OOPM, all members are covered at 100% even if they haven't met their individual OOPM. However the plan document only says "Once a member reaches the out-of-pocket maximum the plan pays 100%..." It does not explicitly say the family OOPM triggers coverage for all. But it's standard. However we must be careful: the prompt says "Report the FINAL components on the books for Claims 19, 20, 25... and the ending accumulators for every member and for the family." It doesn't ask for claim-by claim processing. But we need to know when coinsurance stops (OOPM reached) to compute those claims.
Let's parse the claims and see if OOPM is reached at all.
Given the allowed amounts are large, the family deductible is 6400. We have many claims. Let's process step by step.
We need to compute for each claim:
- deductible_applied
- coinsurance_amount (if any)
- member_responsibility = deductible_applied + coinsurance_amount + copay (0)
- plan_paid = allowed_amount - member_responsibility
And update accumulators:
- member.deductible += deductible_applied
- family.deductible += deductible_applied
- member.oopm += member_responsibility
- family.oopm += member_responsibility
Note: For out-of-network preventive services, they are subject to deductible and coinsurance. In-network preventive services have no cost share and move no accumulator. We have a screening colonoscopy (Claim 13) out-of-network. Is that preventive? "Screening colonoscopy, no polyp removed" - this is a preventive service required to be covered without cost share under ACA when in-network. But it is out-of-network. So it is subject to out-of-network deductible and coinsurance.
Claim 20: Routine immunisation, in-network. Routine immunisation is preventive. In-network preventive: paid at 100%, no cost share, no accumulator movement. So Claim 20 originally (before adjustment) should have 0 member responsibility. But we need the final components after adjustment. The adjustment corrects allowed amount downward. It is still in-network preventive. Does the preventive exemption still apply? Yes, the service is preventive and in-network. So even after adjustment, it should be paid at 100% of allowed amount, with no member cost share. However, we need to verify if the adjustment changes anything else. The reason: "Provider appeal: allowed amount corrected downward after contract rate review." The claim is still a routine immunisation, in-network preventive. So member responsibility remains 0. But we must re-adjudicate: unwinding the original claim's credits and reprocessing at the new allowed amount. The original had 0 member responsibility and 0 deductible. Unwinding does nothing to accumulators (since no credits). Then re-adjudicate: still preventive, so 0 member responsibility. So final components for Claim 20 should be 0 for member responsibility, 745.87 plan paid, 0 deductible, etc. Wait, but if the original claim had no cost share, then unwinding has no effect. The adjustment sets allowed amount to 745.87. Since it's preventive in-network, plan pays 100% of allowed amount = 745.87, member responsibility 0. So plan_paid = 745.87. However, could there be a catch? Some plans only cover preventive services without cost share when in-network, which is the case. So yes.
But wait: The original allowed amount was 1243.12. The adjustment corrects to 745.87. If originally plan paid 1243.12 and member 0, after adjustment plan paid should be 745.87. But in terms of accumulator, nothing changes because there were no member credits. However, plan payments are not tracked in member/family accumulators (only member responsibility and deductible). The prompt asks for ending accumulators only for deductible and OOPM (which is based on member responsibility). So plan payments don't affect accumulators. Good.
But we need to be careful: The adjustment to Claim 20 says "allowed amount corrected downward after contract rate review." The claim itself is still the same service, same network. So still preventive. So yes.
Now Claim 19: B (spouse) urgent care visit, in-network. This is not preventive. So subject to deductible and coinsurance. At the time of Claim 19, we need to know the family deductible status and B's OOPM status.
Claim 25: D (child) physical therapy cour[empty response]Grader detail
json{
"reason": "response did not contain parseable JSON"
}Reasoning · 30,000 tokens
We need to process all ledger lines in order, tracking accumulators for each member and family. The plan is an HDHP with AGGREGATE deductible structure: family deductible in-network 6400. No individual deductible under this structure. However, out-of-network claims use out-of-network individual deductible 6400, and the same single deductible balance (presumably a member-level balance that also accumulates to family? Let's read carefully.
Plan document says:
"Deductible
Individual (in-network) ................ 3200.00
Family (in-network) .................... 6400.00
Structure .............................. AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure.
Out-of-network (individual) ............ 6400.00
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."
Accumulator addendum says:
"A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it:
in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);
out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance.
Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible.
A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance). Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts.
Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
Wait, the in-network deductible threshold under aggregate is the family remainder alone. So for in-network claims, we look at family deductible accumulator (starting at 0, target 6400). Under aggregate, there is no individual in-network deductible. So each in-network claim contributes to the family deductible until family deductible reaches 6400. After that, in-network claims have deductible_applied = 0 and coinsurance begins (10% member, 90% plan). However, member cost share (coinsurance) counts toward OOPM.
But the plan document also says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." This seems contradictory to aggregate family deductible for in-network? Let's parse carefully.
The plan says: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." And the accumulator addendum clarifies:
- For in-network: the deductible_applied is the lesser of allowed amount and the room left under the deductible threshold that applies to it: under aggregate, the family remainder alone.
- For out-of-network: the out-of-network individual remainder, measured against the member's same single deductible balance.
Also: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance."
So there is a "single member deductible balance" that is used for both in-network and out-of-network? But under aggregate, in-network claims use the family remainder, not a member remainder. However, the credits still go to the member's balance and family balance. The phrase "single member deductible balance" might mean that there is one deductible accumulator per member (not separate in-network and out-of-network), but the threshold it's measured against depends on the claim's network status. The out-of-network threshold is 6400 individual. The in-network threshold under aggregate is the family remainder (6400 family). But the family remainder is a family-level accumulator. So for in-network aggregate, the deductible_applied is limited by the family remainder. But the credits are added to both the member's balance and the family balance.
Wait, the addendum says: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." So there are balances: each member has a deductible balance (running total of deductible_applied), and the family has a deductible balance (running total of deductible_applied from all claims). Also each member has an OOP balance (running total of member_responsibility), and family has OOP balance (running total of member_responsibility).
But under aggregate, there is no individual in-network deductible; the plan pays no coinsurance for any member until total family credits reach the family deductible amount. So the family deductible balance must reach 6400 before any in-network coinsurance kicks in. However, the addendum says "in-network ... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate)". This matches: under aggregate, the in-network deductible_applied is limited by the family remainder alone. But the "member's individual remainder" is not used for in-network under aggregate.
But what about the "single member deductible balance"? The plan says in-network and out-of-network credits accumulate to a single member deductible balance. The addendum says out-of-network claims are measured against the out-of-network individual remainder, measured against the member's same single deductible balance. So for out-of-network, the member's deductible balance is the one that matters, with threshold 6400. For in-network under aggregate, the family deductible balance matters, with threshold 6400. But the member's deductible balance also gets credited with the deductible_applied from in-network claims? Let's see: "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." It says out-of-network claims accumulate to member and family. What about in-network? Likely also accumulate to both member and family balances. The family balance is the sum of all deductible_applied across all claims (in and out?). The member balance is the sum of deductible_applied for that member.
But under aggregate, once the family deductible is met, in-network claims have deductible_applied = 0. So no more credits to anyone's deductible balance from in-network claims. Out-of-network claims can still have deductible_applied until the member's out-of-network threshold (6400) is met. But wait, if in-network credits also count toward the member's single balance, then in-network claims could satisfy the out-of-network threshold. 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 implies that the member's deductible balance is increased by both in-network and out-of-network deductible_applied amounts, and when an out-of-network claim is processed, we measure the room left under the out-of-network threshold (6400) against that balance. However, under aggregate, the in-network claims are limited by the family remainder, but they still add to the member's balance. So if a member has a lot of in-network claims, their member deductible balance could reach 6400, meaning subsequent out-of-network claims for that member would have no deductible_applied (since the member's single balance is already at 6400). But the family deductible is also 6400. So in-network claims fill the family deductible and also the member's balance.
But wait, the family deductible threshold is 6400. The out-of-network individual threshold is also 6400. So if a member has in-network claims that contribute to the family deductible, those same amounts are accumulating to the member's single balance. Since the family threshold and the out-of-network individual threshold are the same amount (6400), the member's balance would reach 6400 at the same time the family balance does if all claims were from that member. But with multiple members, the family balance is the sum of all members' in-network deductible_applied (and out-of-network?). Actually, out-of-network claims also accumulate to the family balance. The addendum says out-of-network credits accumulate to the member's balance and to the family balance. It doesn't explicitly say in-network credits accumulate to the family balance, but under aggregate, the family deductible is the total of family credits. The plan says "the plan pays no coinsurance for any member until total family credits reach the family deductible amount." So the family balance is the sum of deductible_applied from all claims (in-network and out-of-network) across all members. Because in-network claims under aggregate are the only way to satisfy the family deductible. But out-of-network claims also generate credits that accumulate to the family balance? The addendum says out-of-network credits accumulate to the member's balance and to the family balance. It doesn't mention in-network credits and family balance, but logically under aggregate the family balance is the total of all deductible_applied from all claims. Actually, the addendum says: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance)." So the family deductible balance is the running total of deductible_applied for all claims? Probably yes. The plan says in-network and out-of-network credits accumulate to a single member deductible balance. It doesn't say the same for family, but the family balance is just the sum of all deductible_applied. The addendum's rule for in-network aggregate: deductible_applied is limited by the family remainder. This implies that the family balance is being tracked.
So the algorithm:
- For each claim, we need to compute:
- deductible_applied: depends on network and plan structure.
- member_responsibility: includes deductible_applied + coinsurance + copay. But this plan has no copays. So member_responsibility = deductible_applied + coinsurance_amount.
- plan_paid = allowed_amount - member_responsibility.
- Also, the claim may be subject to coinsurance after deductible. The coinsurance is applied to the remaining allowed amount after deductible_applied is subtracted? Actually, typically: cost share = deductible_applied + coinsurance% * (allowed_amount - deductible_applied). But we need to check if the plan says "Coinsurance after deductible". Yes. So after the deductible is satisfied (i.e., after deductible_applied reaches the threshold), coinsurance applies to the allowed amount. But for each claim that straddles the deductible threshold, part of it goes to deductible, and the remainder is subject to coinsurance.
Wait, we need to be careful about how coinsurance is computed when the deductible is not yet fully met. Usually, if a claim is processed and the remaining deductible is less than the allowed amount, then deductible_applied = remaining deductible, and coinsurance applies to the rest: (allowed_amount - deductible_applied) * coinsurance_rate. The member_responsibility = deductible_applied + coinsurance_amount. This seems standard.
But the plan document says: "Member cost share is calculated from the ALLOWED amount." That just means we ignore billed charges.
The addendum says: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it... Once the applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible."
So deductible_applied = min(allowed_amount, room_left_under_threshold). Then, after that, if the threshold is met (i.e., room_left was 0), deductible_applied = 0. If room_left > 0 but less than allowed_amount, then deductible_applied = room_left, and the remaining allowed amount is subject to coinsurance? Or is the entire claim subject to coinsurance only after the deductible is fully satisfied? Yes: after the deductible is satisfied, coinsurance begins. So for a claim that partially satisfies the deductible, the portion that goes to deductible is not subject to coinsurance (since it's paying down the deductible), and the remainder is subject to coinsurance. But note: under aggregate, the in-network threshold is the family remainder. Once the family deductible is met, subsequent in-network claims have deductible_applied = 0 and are subject to coinsurance.
However, we also need to consider the out-of-pocket maximum (OOPM). OOPM is the ceiling on member cost share. It includes deductible and coinsurance (and copays if any). Once reached, the plan pays 100% of allowed amount. OOPM has individual in-network 7000, family in-network 14000, individual out-of-network 14000. The family OOPM is for in-network? 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 lists individual (in-network) 7000, family (in-network) 14000, individual (out-of-network) 14000. So there is a family OOPM for in-network. But the addendum says: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This implies that the family OOPM is 14000 (in-network), but out-of-network claims can push the family OOPM balance beyond 14000? Wait, the OOPM is a ceiling; once reached, plan pays 100%. But the addendum says balances are not capped at the in-network amounts. This is a bit confusing. Let's parse: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." So if a member has out-of-network claims, their OOP balance can exceed 7000 (the in-network individual OOPM) because the out-of-network OOPM is 14000. Similarly, the family OOP balance can exceed 14000? Wait, the family OOPM is 14000. Out-of-network individual OOPM is also 14000. There is no family out-of-network OOPM listed. The addendum says "the family balances past the family amounts; the balances are not capped at the in-network amounts." This might mean that the family OOP balance can accumulate beyond 14000 due to out-of-network claims, but the ceiling for in-network is 14000. However, the plan says "Once a member reaches the out-of-pocket maximum the plan pays 100%...". It doesn't say what happens when the family OOPM is reached. Typically, once the family OOPM is reached, all members have 0 cost share for in-network. But the plan document only explicitly says "Once a member reaches the out-of-pocket maximum the plan pays 100%..." It mentions family OOPM but doesn't explicitly state the rule for family OOPM. However, standard insurance: once family OOPM is met, all members have no cost share for in-network. But since the plan document is the governing source, we must see if it specifies family OOPM trigger. The document says: "Out-of-pocket maximum: Individual (in-network) 7000.00, Family (in-network) 14000.00, Individual (out-of-network) 14000.00. 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 say "once the family OOPM is reached, all members..." But in standard plans, the family OOPM is a cap. However, the addendum says "balances are not capped at the in-network amounts." This seems to imply that the OOP balance can exceed the in-network threshold because the out-of-network threshold is higher. But the OOPM is a ceiling; once the ceiling is reached, cost share is 0. If the ceiling is 14000 for out-of-network individual, then the member's OOP balance can't exceed 14000 because once it reaches 14000, the plan pays 100% and member_responsibility becomes 0 for subsequent claims. But wait, "balances are not capped at the in-network amounts" means that if we were to think the OOP balance stops accumulating at 7000 for a member, that's wrong because out-of-network threshold is 14000. So the balance continues to accumulate up to 14000. Similarly, the family OOP balance can accumulate past 14000? The family OOPM is 14000 (in-network). There is no family out-of-network OOPM. The addendum says "the family balances past the family amounts; the balances are not capped at the in-network amounts." This might refer to the deductible balance? Let's read the context: "Because the out-of-network thresholds are higher, out-of-network claims can carry a member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This is under the ACCUMULATORS section, talking about balances (deductible and OOP). So for a member's deductible balance, the in-network individual threshold is 3200 (but under aggregate there is no individual in-network threshold; the family threshold is 6400). However, out-of-network individual threshold is 6400. The member's single deductible balance can go up to 6400. The family deductible balance is also 6400 (in-network family). Out-of-network claims can push the family deductible balance past 6400? The addendum says "the family balances past the family amounts; the balances are not capped at the in-network amounts." So yes, the family deductible balance is not capped at 6400 because out-of-network credits keep adding? But that contradicts the idea of a deductible threshold. Wait, maybe "balances" here refers to the accumulator balances, not the thresholds. The threshold is the amount that must be reached before coinsurance begins. The balance is the running total. Under aggregate, the family deductible threshold is 6400. Once the family deductible balance reaches 6400, in-network claims have deductible_applied = 0. But out-of-network claims can still have deductible_applied because the out-of-network individual threshold is 6400 per member. However, the family balance is the sum of all deductible_applied. If out-of-network claims continue to have deductible_applied (because the member's single balance hasn't reached 6400), those credits also add to the family balance. So the family balance could exceed 6400. The addendum says this is allowed; it's not capped. The family balance is just a running total. But the threshold for in-network claims is the family remainder, which is max(0, 6400 - family_balance). Wait, if family_balance can exceed 6400, then the family remainder would be negative? But the addendum says deductible_applied is the lesser of allowed amount and the room left under the deductible threshold. "Room left" implies if the balance has exceeded the threshold, room left is 0. So for in-network claims after the family balance has exceeded 6400, the family remainder is 0, so deductible_applied = 0. That makes sense.
But what about OOPM? The family OOPM is 14000. Once the family OOP balance reaches 14000, does that mean all members have no cost share for in-network? The plan document does not[empty response]Grader detail
json{
"reason": "response did not contain parseable JSON"
}0DeepSeek V4 Pro · DeepSeek8.2s · 405 out | 8.8s · 406 out | 9.9s · 406 out
json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 150.84,
"claim_25_plan_paid": 1357.51,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 150.84,
"ending_deductible_a": 6400.00,
"ending_oopm_a": 7000.00,
"ending_deductible_b": 6400.00,
"ending_oopm_b": 8075.96,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 4752.77,
"ending_deductible_d": 6400.00,
"ending_oopm_d": 7982.96,
"ending_deductible_e": 6400.00,
"ending_oopm_e": 549.48,
"ending_family_deductible": 32107.33,
"ending_family_oopm": 28361.17
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 150.84,
"ok": false,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1357.51,
"ok": false,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 150.84,
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 6400,
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 7000,
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 6400,
"ok": false,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 8075.96,
"ok": false,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 4752.77,
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 6400,
"ok": false,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 7982.96,
"ok": false,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 6400,
"ok": false,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 549.48,
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 32107.33,
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 28361.17,
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}json{
"claim_19_member_responsibility": 22.05,
"claim_19_plan_paid": 198.41,
"claim_19_deductible_applied": 22.05,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 74.59,
"claim_20_plan_paid": 671.28,
"claim_20_deductible_applied": 74.59,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 150.83,
"claim_25_plan_paid": 1357.52,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 150.83,
"ending_deductible_a": 4456.99,
"ending_oopm_a": 4456.99,
"ending_deductible_b": 8155.44,
"ending_oopm_b": 8155.44,
"ending_deductible_c": 11525.15,
"ending_oopm_c": 11525.15,
"ending_deductible_d": 14716.63,
"ending_oopm_d": 3680.80,
"ending_deductible_e": 14559.11,
"ending_oopm_e": 14559.11,
"ending_family_deductible": 14716.63,
"ending_family_oopm": 26351.89
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 22.05,
"ok": false,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 198.41,
"ok": false,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 22.05,
"ok": false,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 74.59,
"ok": false,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 671.28,
"ok": false,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 74.59,
"ok": false,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 150.83,
"ok": false,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1357.52,
"ok": false,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 150.83,
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 4456.99,
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 4456.99,
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 8155.44,
"ok": false,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 8155.44,
"ok": false,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 11525.15,
"ok": false,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 11525.15,
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 14716.63,
"ok": false,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3680.8,
"ok": false,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 14559.11,
"ok": false,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 14559.11,
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 14716.63,
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 26351.89,
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}json{
"claim_19_member_responsibility": 220.46,
"claim_19_plan_paid": 0.00,
"claim_19_deductible_applied": 220.46,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 745.87,
"claim_20_plan_paid": 0.00,
"claim_20_deductible_applied": 745.87,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 0.00,
"ending_deductible_a": 4602.95,
"ending_oopm_a": 4602.95,
"ending_deductible_b": 14085.96,
"ending_oopm_b": 7344.39,
"ending_deductible_c": 14124.36,
"ending_oopm_c": 5768.37,
"ending_deductible_d": 22219.86,
"ending_oopm_d": 4747.86,
"ending_deductible_e": 22219.86,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 22219.86,
"ending_family_oopm": 23837.26
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 220.46,
"ok": false,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 0,
"ok": false,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 220.46,
"ok": false,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 745.87,
"ok": false,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 0,
"ok": false,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 745.87,
"ok": false,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 4602.95,
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 4602.95,
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 14085.96,
"ok": false,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 7344.39,
"ok": false,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 14124.36,
"ok": false,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 5768.37,
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 22219.86,
"ok": false,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 4747.86,
"ok": false,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 22219.86,
"ok": false,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 22219.86,
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 23837.26,
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}0DeepSeek V4 Flash · DeepSeek430.3s · 17,528 out | 194.4s · 30,000 out | 430.3s · 30,000 out
Reasoning · 16,134 tokens
We need answer JSON only. Need compute ledger. Need understand plan: Trinity HDHP 3200, plan year 2026, aggregate deductible in-network family 6400? Wait plan document says Deductible Individual in-network 3200, Family in-network 6400, Structure AGGREGATE — "the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." But also addendum accumulators says: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: in-network ......... the smaller of the member's individual remainder and the family remainder (embedded), or the family remainder alone (aggregate);" So under aggregate, for in-network claims, deductible_applied uses family remainder alone (no member individual). So family deductible threshold is 6400 for in-network family? For out-of-network: "out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance." Also Out-of-network individual deductible 6400. "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 deductible balance (accumulated credits from in-network and out-of-network claims), and when service is out-of-network, threshold is 6400 individual OON. For in-network under aggregate, threshold is family 6400 for all members combined? Need parse. Family total deductible balance accumulates all members' deductible_applied? It says family total deductible, out-of-pocket. We need ending_family_deductible likely sum member balances? "Family total deductible 0.00 out-of-pocket 0.00". "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance." So member deductible balance is running total of deductible_applied. Family deductible balance is running total of family deductible_applied? likely sum of member deductible_applied? Under aggregate, each claim's deductible_applied (deductible credit) goes to member and family total. But plan pays no coinsurance until total family credits reach family amount. Need compute.
Let's define per claim adjudication:
- Allowed amount = amount plan recognizes.
- Pre-cert? Preventive in-network no cost share and no accumulator. Out-of-network preventive subject to OON deductible and coinsurance. Need identify preventive services: "Generic retail pharmacy fill" not preventive; "Annual wellness visit" out-of-network likely preventive? Routine immunisation in-network preventive. Screening colonoscopy no polyp removed out-of-network maybe preventive? Given plan document: "Preventive care In-network preventive services required to be covered without cost share are paid at 100%...". For out-of-network preventive subject to OON deductible and coinsurance (given general rules).. Need decide for services "Annual wellness visit" and "Screening colonoscopy, no polyp removed" are preventive required? Likely yes, they are preventive services at 100% only if in-network; out-of-network subject to OON deductible and coinsurance. They are out-of-network so subject to OON. We'll apply OON deductible.
- Routine immunisation, in-network: preventive, no cost share, no accumulator. But later Claim20 adjusted downward allowed corrected to 745.87, and it was routine immunisation in-network. Since in-network preventive, even adjustment? It should remain no cost share, no accumulator. But it was adjusted due allowed amount corrected downward. Need re-adjudicate Claim20 at corrected allowed amount: if preventive, member_responsibility = 0, deductible_applied=0, plan_paid = allowed amount? The plan pays 100% allowed for covered in-network preventive services, not subject to deductible. So plan_paid 745.87. But original processing? Need unwinding original's credits from accumulators then reprocess. If original had no member responsibility and no deductible_applied, then no credits to unwind. Plan_paid changes from 1243.12 to 745.87. Does plan_paid affect accumulators? No only member_responsibility for OOPM; premium noncovered? Plan_paid not in accumulators unless? It doesn't. So adjustment to preventive simply plan_paid corrected, no member cost share. Need report Claim20 final components: responsibility 0, plan_paid 745.87, deductible_applied 0, copay 0, coinsurance 0. But need ensure no OOPM touched: member_responsibility 0. Yes.
Need process all lines in order, maybe claim19,20,25 finals after adjustments/void. Need ending accumulators after all lines, including adjustments and voids. Need compute family deductible balance, OOPM balances.
We need be very careful with aggregate vs OON thresholds, adjustments/voids re-adjudication against current accumulators. Need simulate ledger.
Let's restate plan:
- No copays all services subject deductible then coinsurance.
- In-network coverage after deductible: 10% member /90% plan.
In-network deductible aggregate family 6400; no individual. For in-network claim, deductible_applied is lesser of allowed amount and room left under family remainder alone (aggregate), if family deductible balance < 6400. Once family threshold met, deductible_applied =0 for subsequent in-network; member coinsurance 10% of allowed after deductible? With aggregate, no coinsurance for any member until total family credits reach family amount. Once family deductible met, all members coinsurance 10% of allowed? Let's infer: Coinsurance after deductible in-network 10% member. Under aggregate, the plan pays no coinsurance for any member until total family credits reach family deductible amount. So before family met, member paid 100% of allowed as deductible_applied? And deductible_applied is lesser of allowed amount and family remainder, so if claim crosses threshold? If allowed exceeds remaining family deductible, deductible_applied = remaining family deductible (not full allowed), and after family met, remaining allowed subject to coinsurance for that claim? Need adjudication formula: Deductible applied is LESSER of allowed amount and room left under deductible threshold. Once applicable threshold met, deductible_applied is 0.00. It implies when crossing deductible, deductible_applied = remaining room (not entire allowed?), then coinsurance applies to remainder? Need think. For HDHP, typically apply allowed amount to deductible until deductible met; once met, coinsurance applies on remaining charges. If claim allowed 500, family remaining 300, member pays 300 deductible + 10% of 200? Or does "deductible_applied is lesser of allowed amount and room left" => deductible_applied=300. What about remaining 200? It must be subject to coinsurance? Member_responsibility total = deductible_applied + coinsurance_amount (after deductible). "Coinsurance after deductible" means after deductible is satisfied, member percentage share of allowed amount after deductible. In this harness, likely claim components: deductible_applied; coinsurance_amount; copay_amount; member_responsibility = deductible_applied + coinsurance_amount? Task says for a claim components: member_responsibility plus plan_paid equals allowed amount. Need member_responsibility includes deductible_applied + coinsurance? Copay maybe flat. This plan no copays, so copay_amount 0. Coinsurance_amount = allowed amount minus deductible_applied times member coinsurance% after deductible? Need calculate. But if family aggregate not fully met, no coinsurance for any member until total family credits reach family amount. So for claim before family met: if allowed <= remaining family deductible, deductible_applied=allowed, coinsurance=0, member_responsibility=allowed, plan_paid=0. For crossing claim: allowed > remaining family deductible, deductible_applied = remaining family deductible, then after deduct fully satisfied? Does coinsurance apply to remainder immediately? "Once applicable threshold is met, deductible_applied is 0.00" and "plan pays no coinsurance for any member until total family credits reach family deductible amount." On crossing claim, total family credits reach family amount, so coinsurance applies to allowed minus remaining? Likely yes: after the deductible is satisfied within claim, coinsurance applies to the rest. But aggregate says no coinsurance until total family credits reach family deductible amount. At crossing, after crediting remainder, threshold reached, then coinsurance applies on excess. Need see plan document wording: "Deductible ... Family ... Structure AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount." Thus for a claim that causes family credits to reach, after the deductible portion is applied, remaining amount is subject to coinsurance? "plan pays no coinsurance ... until total family credits reach..." So for the crossing portion, the family credits reach before computing coinsurance, so yes coinsurance on remainder. Need calculate accordingly.
- For out-of-network, each member has OON individual deductible threshold 6400. Since OON service always uses OON individual remainder, not family remainder? Addendum: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." So for OON claim, deductible_applied = lesser of allowed amount and OON individual remainder = max(0, 6400 - member's accumulated deductible balance? Wait threshold for OON is 6400 but member may have accumulated deductible credits from previous in-network and OON claims (same single balance).. The balance is running total of deductible_applied. Member's OON individual remainder = 6400 - member.deductible_balance? The plan document says Out-of-network individual deductible 6400. Addendum: "A claim's deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: ... out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance." So yes use member.deductible_balance, not family remainder. Threshold 6400, and because balance includes in-network credits, OON room = max(0,6400 - balance).. If member balance already >= 6400, no deductible_applied, and coinsurance applies.
But "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." Each member's balance accumulates their own deductible_applied from both IN and OON. Since aggregate in-network uses family threshold not member, deductible_applied for IN claim credits to member's balance? Under aggregate, "no individual deductible"; in-network deductible_applied uses family remainder alone. Does that credit to member's own deductible balance? Accumulator says each member has deductible balance. "A claim's deductible_applied ... out-of-network ..... measured against the member's same single deductible balance." In-network threshold family; deductible_applied credits to member's balance? Family total? The ledger has member deductible and family total; "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." I think each claim's deductible_applied, regardless in/out-of-network, accumulates to that member's balance and to family total. But in-network deductible_applied measured against family remainder; yet credits add to member balance. Yes.
OON claim's OON room is based on member's accumulated deductible balance from all claims. If member's balance already >6400? OON deductible already met. If member hasn't had claims enough, OON deductible_applied applies. Because aggregate family might be at 6400 but OON threshold not met for member, so OON claim can still have deductible_applied? Addendum says OON claims measured against OON individual thresholds only; family amounts (in-network) do not limit OON. So even if family deductible met, an OON claim for member with individual balance<6400 gets deductible_applied until individual OON threshold? But "member deductible balance" is same as family? Let's parse: "Out-of-network (individual) deductible 6400.00" 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 yes member has balance; OON threshold 6400. In-network aggregate threshold family 6400 applies only to IN services; family total threshold; member balance is just recording? But for OON, threshold based on member balance. Even if family met, OON not met for member if member balance<6400; thus OON claims continue deductible.
But wait individual (in-network) deductible listed 3200, but structure aggregate says no individual deductible under this structure. So ignore 3200 in network. Out-of-network individual 6400 is separate individual threshold. Good.
OOPM: Individual in-network 7000, Family in-network 14000, Individual out-of-network 14000. "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services." Need compute OOPM balance as running total of member_responsibility? Addendum: "A balance is the running total of deductible_applied (for a deductible) or of member_responsibility (for an out-of-pocket balance." For member OOPM, balance accumulates member_responsibility from claims that generate cost share? "Member's own accumulator andfamily accumulator both move on every claim that generates cost share." So each member's OOPM balance = sum of their member_responsibility from all claims (including deductibles/coinsurance? Responsibility includes all member cost share). Family OOPM balance likely sum all members' member_responsibility? Or maybe family OOPM uses family OOPM threshold 14000? Under aggregate, family OOPM? Plan says Individual OOPM 7000, Family 14000. "Once a member reaches..." So OOPM maybe individual level, and family aggregate? Need ending_family_oopm likely sum of member OOPM balances? The ledger shows family total OOPM. In OOPM, plan pays 100% once member reaches their OOPM; family OOPM maybe not relevant because there is no aggregate? Need understand harness family accumulator. For plan family-level deductible/family OOPM? The task asks ending_deductible_a etc and ending_family_deductible, ending_family_oopm. We need compute running totals per member and family total. Under aggregate deductible, family deductible is sum member deductible_applied? Family OOPM is sum member_responsibility? likely yes. Need simulate.
Need be precise on "member_responsibility" calculation for each claim and adjustments. Let's establish formula:
- For a non-preventive service:
Deductible_applied = amount applied to deductible based on relevant threshold:
IN: if service in-network: threshold = family deductible (6400) minus family_deductible_balance? Wait "room left under deductible threshold that applies to it: in-network ......... the smaller of the member's individual remainder andthe family remainder (embedded), or the family remainder alone (aggregate);" So in aggregate, room = family_remainder = 6400 - family_deductible_balance (family total of deductible credits).). Deductible_applied = min(allowed, room).
What if family_deductible_balance already >=6400? room=0 -> deductible_applied=0.
OON: threshold = member OON individual remainder = 6400 - member_deductible_balance (member's own cumulative deductible_applied from all claims).? Deductible_applied = min(allowed, member_OON_room)..
- Coinsurance_amount: For service subject to coinsurance after deductible, after applying deductible_applied, remaining allowed = allowed - deductible_applied. But plan has no copays. Member coinsurance percentage depends on network: IN 10%, OON 40%. However aggregate says "plan pays no coinsurance for any member until total family credits reach family deductible amount." For IN claims, before family threshold met, no coinsurance (=0); after family threshold met at or before claim, coinsurance = 10%*(allowed - deductible_applied).). But if a claim crosses family threshold, after applying deductible_applied to reach family threshold, "until total family credits reach family amount" is satisfied, so coinsurance applies to remainder? Should calculate coinsurance on full allowed minus deductible_applied? Need confirm with "deductible_applied is lesser..." not "deductible applied until threshold; no coinsurance on remainder until next claim." Plan language: "Coinsurance after deductible, in-network .........10%" Standard: deductible is met after applying claim portion; coinsurance applies to same claim's remainder. I think yes. Need use.
For OON, no aggregate restriction; after OON deductible for that member? If member's OON deductible not met, deductible_applied consumes allowed until threshold; coinsurance applies to remainder at 40%. But if member's balance already >=6400, coinsurance=40% all allowed; deductible_applied=0. If claim crosses member's OON threshold, remainder subject to 40%. Yes.
- "Once applicable threshold is met, deductible_applied is 0.00" no cap? Hmm.
- member_responsibility = deductible_applied + coinsurance_amount + copay? With no copay, yes. Plan pays = allowed - member_responsibility. For adjustments to preventive, plan_paid=allowed, member_responsibility=0.
.
Need process all lines, maintaining:
- member_deductible_balance A/B/C/D/E = cumulative deductible_applied for each member (regardless network? Yes all deductible credits).
- family_deductible_balance = sum member_deductible_balance? Or separate? It should update on each claim's deductible_applied. In aggregate, in-network room depends on family_deductible_balance. OON room NOT dependent on family; but OON deductible_applied still accumulates to family total? Addendum: "The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." So family_deductible_balance includes OON deductible_applied too. Yes.
- member_OOPM_balance = cumulative member_responsibility for each member? Thresholds for benefits: IN individual 7000, OON individual 14000. Need when applying OOPM to reduce member responsibility? Plan says "Once a member reaches the out-of-pocket maximum the plan pays 100% of the allowed amount for covered services for remainder." The harness likely calculates responsibility as usual but if member_OOPM_balance + member_responsibility would exceed OOPM threshold, plan pays excess? Usually OOPM caps member cost share; once reached, coinsurance/deductible waived. Need incorporate OOPM. The task asks ending_oopm; likely final member OOPM balance capped at individual OOPM? But under family plan, individual OOPM maybe applies per member, family OOPM maybe sum? Need look at plan: OOPM Individual in-network 7000.00; Family in-network 14000.00; Individual out-of-network 14000.00. "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." This indicates member-level OOPM. What is family OOPM for? Maybe family total cap, but if each member capped at 7000, family could total 35000; family OOPM prevents family total cost share beyond 14000 after all members? But wording only "Once a member reaches..." not family. Addendum: "A member's own accumulator andthe family accumulator both move on every claim that generates cost share." Family OOPM likely sum of member_responsibility (uncapped?) or capped at family 14000? Need interpret. The ledger shows family total OOPM. Under typical family plans with embedded individual json{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount":": 0.00,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 1786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8430.86,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3298.76,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 1373.69,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 14000.00
}
Grader detail
json{
"reason": "response did not contain parseable JSON"
}Reasoning · 27,454 tokens
We need answer JSON only. Need compute. Need be careful. Need understand plan: aggregate deductible family in-network 6400, individual in-network 3200 but structure aggregate: "AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure." But glossary says aggregate family amount must be satisfied in full before plan pays for any member. Yet accumulator addendum: in-network deductible_applied is lesser of member individual remainder and family remainder (embedded) OR family remainder alone (aggregate). So aggregate: in-network claims apply toward family deductible until family remainder, no member-level individual cap. Out-of-network: "deductible_applied is ... out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance." Also out-of-network thresholds: OON individual 6400, OON OOPM 14000. Family amounts are in-network amounts, do not limit OON claim. Credits accumulate to member's balance and family balance. So for OON claims, deductible_applied is based on member's OON individual deductible remainder (threshold 6400), but member's balance includes all prior deductible_applied (IN and OON?) Plan doc says in-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance. The amount above is threshold that balance measured against when service OON. So yes same balance (all credits) with IN threshold 3200 but since aggregate? "There is no individual deductible under this structure" for in-network. But for OON, out-of-network (individual) 6400, and balance measured against that threshold. Need compute.
No copays. For each claim allowed amount, apply deductible_applied, then coinsurance member % of remaining allowed (IN 10%, OON 40%)? "Coinsurance after deductible" member percentage share of allowed amount after deductible is satisfied. If allowed <= remainder, deductible_applied equals full allowed, member coinsurance 0, plan paid 0? But member responsibility equals deductible_applied + coinsurance? Need know components.
We need report final components on books for Claim 19, 20, 25: member_responsibility, plan_paid, deductible_applied, copay_amount, coinsurance_amount. For claim adjusted/voided report as adjusted/voided. Claim20 adjusted Line23 lower allowed to 745.87; need re-adjudicate Claim20 at adjusted allowed against accumulators as they stand at adjustment. But they ask report final components for Claim20 as re-adjudicated by adjustment. Claim19, Claim25 not adjusted? Need final components from original adjudication? Claim25 line25 processed after adjustment; yes no adjustment to it. Need compute all claims in order to ending accumulators. Need include voids and adjustments unwinding. Need calculate running accumulators carefully.
We need process ledger lines in order. Need maintain per member deductible balance (single balance?) and OOPM balance (member_responsibility total? Need accumulators defined: deductible balance is running total of deductible_applied. OOP balance is running total of member_responsibility. For family total sum members. There are individual member accumulators and family totals. No individual in-network deductible under aggregate? But member deductible balance still tracks all credits, and family balance same? Since all credits accumulate to family too. For IN claims, deductible_applied = family remainder alone under aggregate, not member individual remainder. The member's balance gets that credit. Family total also gets same credit. But there is no separate individual remainder? Actually "Family total deductible" maybe sum of member deductible balances. If each claim's deductible_applied credited to member and family, family total equals sum members if all including same? likely yes. For OON, deductible_applied = out-of-network individual remainder, measured against member's same single deductible balance threshold 6400. Credits accumulate to member's balance and family. In aggregate, family deductible threshold 6400? But OON threshold says family amounts do not limit OON. Need check addendum: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." So for OON claim, remaining deductible room = min? Actually "deductible_applied is the LESSER of its allowed amount and the room left under the deductible threshold that applies to it: in-network ... out-of-network ..... the out-of-network individual remainder, measured against the member's same single deductible balance." So for OON: threshold 6400 member's OON individual remainder = 6400 - member's single balance? But member's single balance may include IN family? All credits to same single member balance. So yes remainder = max(0, 6400 - member_deductible_balance). If allowed less than remainder, full allowed deductible_applied, else remainder. Member OOP balance accumulates member_responsibility (deductible + coinsurance). OOPM threshold for OON 14000. Need OOPM? "Individual out-of-pocket maximum 14000" maybe applies to total member responsibility? Once reaches OOPM plan pays 100% allowed for covered services. Need need consider OOPM reached by any member? likely no? Need check. We'll compute.
Need be careful with adjustment/void: unwinds named claim's credits from every accumulator they touched and re-adjudicates that claim at corrected values against accumulators as they stand at adjustment. If ADJUSTMENT to claim20: original Claim20 processed line20, then void? Actually adjustment to Claim20 line23: remove credits claim20 generated (deductible credit and member responsibility from member's and family's accumulators), then adjudicate again at corrected values against accumulators as they stand at adjustment. Claims in between not reprocessed. Need at adjustment point, accumulators include effects of all prior lines (including line20 original and lines21-22? Actually line22 before line23? Yes line23 after line22. Process in order. At line23, before adjustment: We remove original Claim20 credits from current accumulators (which include original Claim20 plus later claims). Then re-adjudicate Claim20 corrected against post-removal accumulators? Wording: "credits that claim generated... are removed from every accumulator they touched... and the claim is adjudicated again at its corrected values against the accumulators AS THEY STAND at the point the adjustment is processed." Need order maybe remove then re-adjudicate? "When a line is an adjustment... credits... are removed... and the claim is adjudicated again at its corrected values against the accumulators AS THEY STAND at the point the adjustment is processed." The accumulators as they stand at adjustment include original credits, unless removed? Usually processing adjustment: reverse original then process corrected. "unwinds the named claim's credits from every accumulator they touched and re-adjudicates that claim at its corrected values against the accumulators as they stand at the adjustment" Could mean after removal, accumulators at point adjustment excluding original? Need need parse. "ADJUSTMENT. When a line is an adjustment to an earlier claim, the credits that claim generated — its deductible credit and its member responsibility — are removed from every accumulator they touched (the member's and the family's), and the claim is adjudicated again at its corrected values against the accumulators AS THEY STAND at the point the adjustment is processed. Claims processed between the original and the adjustment are NOT reprocessed; their results stand as first adjudicated." So yes remove original credits from current period-end (after claims through line22), then re-adjudicate corrected against the accumulators after removal? "AS THEY STAND at the point the adjustment is processed" could after removal? It says remove then adjudicate. We'll implement remove original, then adjudicate adjusted against current accumulators (which include later claims, excluding original). If allowed corrected lower, deductible_applied could be based on room at adjustment after removal. Need calculate.
Void similar: remove credits, nothing replaces. Claim3 void line14; Claim6 void line16. Need remove original Claim3/6 credits from accumulators after lines up to line13/15? Need at void line14, before void accumulators include line1-13. Remove Claim3 credits from all. No replacement. Similarly Claim6 void at line16: before void accumulators after line15 including Claim6 original? Actually Claim6 line6. Lines1-15 processed (including Claim15); original Claim6 credited remains unless voided now. Remove at line16. No replacement. Need update ending accumulators.
Need compute final components for Claim19,20,25. Claim20 adjusted: final components as re-adjudicated by adjustment. Need know at adjustment cumulative accumulators excluding original and including claims1-22? include later claims? yes claims processed between original and adjustment (line21,22) remain. So Claim20 re-adjudicated against accumulators after removing original Claim20 from state after line22? Let's compute carefully.
Need "report the components from the adjustment" for adjusted. components = at adjustment's re-adjudication.
. Need compute claim20 allowed corrected 745.87 in-network? Claim20 routine immunisation, in-network. Important: Routine immunisation is preventive? Plan doc: "In-network preventive services required to be covered without cost share are paid at 100% of allowed amount and are not subject to deductible, coinsurance, or a copay." Line20 Service: Routine immunisation, in-network. Is routine immunisation preventive service required to be covered without cost share? Likely yes: routine immunisation is preventive service. Need treat as preventive in-network: no cost share, no accumulator. But if adjusted, still preventive? Provider appeal corrected allowed downward after contract rate review. If in-network preventive service, adjusted allowed 745.87 paid at 100% plan, member_responsibility 0, deductible_applied 0, copay 0, coinsurance 0. Need check original Claim20 line20: Routine immunisation, in-network. Should be preventive no cost share. But why allowed? Could be no deductible, plan_paid full allowed. Need when adjusted, correction downward only plan_paid changes from 1243.12 to 745.87? Original presumably plan paid 1243.12, member 0, no accumulator. Adjustment would remove? If no member_responsibility and no deductible_applied, there are no credits? It "credits that claim generated — its deductible credit and member responsibility — are removed" Neither if preventive. Thus adjustment simply posts corrected allowed? But final components: member_resp0, plan_paid745.87, deductible0, copay0, coinsurance0. Need confirm.
However there is line20 routine immunisation, in-network, billed 2299.77 allowed 1243.12. The plan document says preventive services in-network carry no cost share and move no accumulator. Routine immunization is likely preventive. Need no OOPM. So no deductible. Thus no impact accumulators. Claim20 adjusted downward no accumulator effect; final as paid 745.87.
Claim19 urgent care in-network line19 allowed 220.46. Need apply accumulators as they stand before line19 after all previous including line18. Need compute running balances through line18, with void/adjust? Void line14,16 before. Need compute.
Claim25 physical therapy in-network line25 allowed 1508.35. Need accumulators after line24. Need final.
Need compute all lines to determine ending accumulators. Let's carefully compute using plan aggregate/family/OON.
We'll need maintain per member deductible balance and OOP balance. But under aggregate, for in-network claims, deductible_applied = min(allowed, family_deductible_remainder) because "family remainder alone" regardless of member. Family remainder = 6400 - family_total_deductible? Wait "family amount must be satisfied in full before plan pays for any member." Family total accumulator is sum of member credits. For IN claim, eligible deductible_applied equals lesser of allowed and "family remainder alone" where family remainder likely 6400 - family total deductible. Thus if family total reaches 6400, no deductible applied for any IN claims thereafter (coinsurance begins for all members). However member's own balance also credited same amount. The family total always increments by any claim's deductible_applied. So effectively first 6400 of allowed for IN claims across family are deductible, then no deductible. No individual thresholds. For OON claims, deductible_applied uses member's OON individual remainder threshold 6400, not family; so OON claims can consume deductible after family met? If family total perhaps at6400, IN claims no deductible but OON claims still may have deductible for that member until member balance reaches6400? Need understand single balance: OON threshold 6400 measured against member's deductible balance (not family? But "member's same single deductible balance"). Family total is sum members. But if family aggregate no individual, IN claims use family remainder; individual member's balance still gets credit? The family total maybe equals sum member balances. For OON, family total doesn't limit but member's balance maybe includes all credits. Is there a separate family threshold for OON? No. Thus OON claim's deductible_applied can push member's balance above6400? Wait threshold OON individual 6400; if member's balance already maybe some credits from family IN claims, even if family total met, OON deductible room may be 6400 - member's balance; could be less, could be positive. It doesn't matter family. Once member's single balance reaches6400, OON deductible satisfied for that member (and perhaps all IN no deductible after family fixed). However due aggregate, IN claim's deductible_applied is family remainder alone; if family total below6400, it may credit to member's balance though member's balance maybe positive. If family total at6400, IN claims no deductible, but member balance no change; OON member can still have deductible if member's balance<6400. That seems possible. Need compute.
Need also OOPM: member OOP balance = running total member_responsibility (deductible_applied + coinsurance? no copay).. The OOPM for IN 7000 individual; for OON 14000 individual? Actually plan doc: Individual(in-network)... 7000, Family(in-network)...14000, Individual(out-of-network)...14000. How measure? "Once a member reaches the out-of-pocket maximum the plan pays 100%..." Need likely if member reaches applicable OOPM? For IN claims, OOPM threshold 7000. For OON claims, OON OOPM threshold 14000. The member's OOP balance is same running total all member responsibility? Need "Individual (out-of-network) 14000" maybe if service out-of-network, threshold measured against member's OOP balance? Same balance? Need need compute perhaps no one reaches OOPM? We'll check. Member A/B/C/D/E maybe large out-of-pocket due OON could approach? Need totals maybe less than 7000? Need compute. But for final accumulators ending_oopm_a etc likely values can exceed? Need exact.
Let's process sequentially. I'll use Excel-like manual. Need be very careful. We'll create table columns: line, claim, member, network, allowed, family_ded_rem before? Deductible_applied for IN: min(allowed, fam_rem_before) if fam_rem>0 else0. For OON: min(allowed, max(0, 6400 - member_balance_before)? because threshold OON individual 6400, but if member balance may exceed threshold no. Need member deductible balance is same running total all previous deductible_applied for that member. Is it capped at 6400? Addendum says balances are not capped at in-network amounts; OON thresholds higher, OON claims can carry past in-network amount; family balances past family amounts; balances not capped at in-network amounts. For OON threshold 6400: once balance >6400, no deductible. If member_balance before e.g. 5000, OON rem 1400. After deductible applies 1400, balance 6400. Good. If member_balance before 3000, OON rem 3400, if allowed less=> all deductible. Balance increases. The balance may include IN deductible credits but those were under family aggregate and credited to member's balance? Need yes. Even though no individual IN threshold, member's balance is same single deductible balance. But maybe for in-network claim under aggregate, "deductible_applied is family remainder alone"; it still creates member credit. So OON threshold measured against member's balance. Okay.
However need determine "member's balance" for OON includes family aggregate credits? Plan says "in-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance." all credits. So yes.
.
Need also when family deductible met, IN claim's deductible_applied 0, so no member balance credit. OON may still have member balance below6400.
.
Need process lines:
Line1 Claim1 A IN generic pharmacy allowed74.87. Family ded rem before 6400. Ded_app=74.87 (since min74.87,6400). Member A balance +=74.87. Family ded balance =74.87. Member_resp =74.87? Coinsurance after deductible: allowed-after-ded=0, coinsurance=0. Plan_paid=0. Member responsibility = deductible + coinsurance =74.87. OOPM A balance +=74.87. Is plan_paid 0? For allowed fully within deductible, yes plan pays 0; member pays 74.87. Note allowed amount=74.87. member_resp+plan_paid=74.87. Good.
Line2 Claim2 C OON inpatient allowed10883.95. Member C balance before=0; OON rem=6400. Ded_app=min10883.95,6400=6400. Remainder after ded=4483.95. Coinsurance OON 40% of4483.95=1793.58. Member_resp=6400+1793.58=8193.58. Plan_paid=60%? Actually plan_paid should allowed - member_resp =2690.37? Wait allowed 10883.95 - 8193.58=2690.37. Coinsurance plan share 60% of4483.95=2690.37. Good. Deductible balance C +=6400. Family ded total before74.87+6400=6474.87? Wait family ded balance family sum? Deductible family threshold 6400; but C OON claim credits 6400 to family total. Family total before=74.87; after=6474.87, exceeding6400. That's allowed? Addendum "family balances past family amounts; not capped." For future IN claims, family deductible remainder = max(0, 6400 - family_total?) But family_total already exceeded 6400; then remaining 0. So IN no deductible. For C OON threshold member balance=6400 so future OON for C maybe no deductible? Actually C member balance 6400, OON rem=0. So C subsequent OON no deductible (coinsurance after deductible? Yes no deduct, coinsurance 40% of allowed? But for OON after deductible satisfied? Let's date:
Line3 Claim3 C OON diagnostic lab allowed967.99. Member C balance before=6400 (from line2), OON rem=0. Ded_app=0. Coinsurance40% of967.99=387.196 ->387.20. Member_resp=387.20. Plan_paid=580.79 (967.99-387.20=580.79). Ded balance C remains 6400 (not capped? Ded_app 0 no increase. Family ded total unchanged 6474.87. OOPM C +=387.20.
Line4 Claim4 A IN urgent care allowed255.34. Family ded total before=6474.87 >6400, fam rem=0. IN ded_app=0. Coinsurance10% of255.34=25.534 ->25.53. Member_resp=25.53. Plan_paid=229.81. Ded A remains74.87; no new ded credit? Under aggregate, deduct_app=0 because family met. A balance for OON threshold still74.87. OOP A +=25.53. Good.
Line5 Claim5 A IN emergency allowed3545.18. Family rem=0. Ded_app=0. Coinsurance10%=354.518 ->354.52. Member_resp=354.52. Plan_paid=3190.66? 3545.18-354.52=3190.66. A ded balance unchanged74.87, OOP +354.52.
Line6 Claim6 A IN allergy testing allowed911.89. Family rem=0. Ded_app=0. Coinsurance10%=91.189 ->91.19. Member_resp=91.19. Plan_paid=820.70? 911.89-91.19=820.70. OOP A +=91.19. Ded A unchanged74.87.
Line7 Claim7 B IN ambulatory surgery allowed7845.50. Family rem=0 (b[empty response]Grader detail
json{
"reason": "response did not contain parseable JSON"
}Reasoning · 28,476 tokens
We need answer JSON only. Need process ledger carefully. Need compute final components for claims 19,20,25 (claim20 adjusted? line23 adjustment to Claim20), and ending accumulators per member/family. Need understand plan aggregate family deductible, OOPM. Need track all lines in order, including savings? Need compute final on books for claim20: adjustment re-adjudicates at corrected allowed amount 745.87 against accumulators as at adjustment line23 after unwinding original claim20 credits. Need report components from adjustment. For claim19 and25 no later adjust? claim25 is line25 no adjustment. Need compute components at line19 (claim19) and line25 (claim25) as originally adjudicated (no adjustments?) Claim25 later none. Need final ending accumulators after all lines processed including voids and adjustments.
Need be meticulous. Let's parse plan.
.
TRINITY HDHP 3200
Aggregate deductible family in-network 6400. Deductible structure AGGREGATE — no individual deductible; plan pays no coinsurance for any member until total family credits reach family deductible amount. Wait for in-network? It says Deductible: Individual(in-network) 3200; Family(in-network) 6400; Structure AGGREGATE — the plan pays no coinsurance for any member until total family credits reach the family deductible amount. There is no individual deductible under this structure. So for in-network claims, deductible_applied lesser? Accumulator addendum says: deductible_applied is LESSER of its allowed amount and room left under deductible threshold that applies to it: in-network .........the smaller of member individual remainder and family remainder (embedded), or family remainder alone (aggregate); out-of-network ..... out-of-network individual remainder, measured against member's same single deductible balance. So use family remainder for in-network; out-of-network uses OON individual threshold 6400 maybe measured against member's balance, not family? Need interpret.
Plan has aggregate family deductible in-network amount 6400. But out-of-network individual deductible 6400. "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." Addendum: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." Hmm this suggests each member has a single deductible balance that accumulates all deductible credits; for in-network claim, threshold = family remainder alone (aggregate), no individual; for out-of-network, threshold = OON individual remainder 6400 - member's balance? Actually "measured against the out-of-network individual remainder" measured against out-of-network individual threshold only. But accumulators balance for family total? Need understand: Aggregate family deductible: no member reaches coinsurance until total family credits reach family amount. But out-of-network claims measured against OON individual threshold only; family amounts do not limit OON claim. The credits an OON claim generates still accumulate to member's balance and family balance. Need process exactly.
This plan has aggregate family deductible. For in-network claims, no coinsurance for any member until total family credits reach $6400 family deductible. Thus before family deductible met, in-network claim deductible_applied = allowed amount? Actually if within family remaining; once family deductible met, deductible_applied 0 and coinsurance applies for in-network 10%. Since aggregate, no individual; so for in-network allowed $74.87 line1, family remaining 6400, deductible_applied 74.87, member responsibility? In-network once deductible? No copays, subject to deductible then coinsurance. If deductible applied equals allowed amount? Then member pays allowed amount as deductible, no coinsurance because after deductible? Coinsurance after deductible applies to remaining allowed amount after applying deductible. Deductible_applied = lesser allowed and remaining deductible; if allowed <= deductible remaining, deductible_applied allowed, coinsurance amount 0, member_resp = deductible_applied? Need compute member_responsibility = deductible_applied + coinsurance_amount? Wait plan: Coinsurance after deductible, in-network 10% member. Deductible amount member pays at allowed rate before coinsurance begins. If deductible_applied = amount of allowed consumed to satisfy deductible, and coinsurance = member percentage of allowed amount after deductible satisfied? Need formula likely coinsurance_amount = (allowed amount - deductible_applied) * coinsurance rate. If deductible_applied=allowed, coinsurance=0. Member responsibility=deductible_applied+coinsurance. Need confirm with required components includes deductible_applied, copay_amount, coinsurance_amount, member_responsibility. Yes likely.
For out-of-network claims: Before OON deductible threshold met? Deductible_applied = allowed amount? Threshold OON individual 6400 per member? Since no individual ded in-network but OON individual threshold 6400. Family aggregate in-network maybe irrelevant for OON for applying deductible; but for member's OON deductible, if allowed less than remaining OON deductible balance, full allowed applied to deductible and no coinsurance? Actually after deductible then coinsurance OON 40%. So if allowed amount <= OON deductible remainder, deductible_applied=allowed, coinsurance=0, member_resp=deductible. If allowed amount exceeds OON deductible remainder, deductible_applied=remaining threshold, coinsurance=40% of (allowed - deductible_applied). member_resp=deductible_applied+coinsurance. But what about family aggregate for OON? Addendum says out-of-network claims measured against OON individual thresholds only; family amounts, in-network amounts, do not limit an OON claim. However "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 is single member deductible balance maybe cumulative in+OON. For OON claim, threshold is OON individual remainder? Need define remainder = threshold - member's balance? since single balance accumulates all ded credits. If member's balance may exceed in-network individual 3200 but less than OON threshold6400, then OON claim's available room = 6400 - balance. For aggregate family? For in-network, threshold is family remainder alone, not individual, and plan pays no coinsurance until family total credits reach family amount. But an OON claim is measured against OON individual threshold only; family amounts do not limit OON claim. That means even if family aggregate family deductible $6400 not met or met, OON claim can use up to remaining OON individual threshold for that member, not family remaining. Also credits OON accumulate family balance. Need track.
Important: OOPM. Plan has out-of-pocket maximum individual in-network 7000, family 14000, individual OON 14000. Once member reaches OOPM plan pays 100%. Need track member_responsibility accumulators toward OOPM; family OOPM? Need know thresholds for OOPM apply. Addendum: "A claim's deductible_applied ... Once applicable threshold is met, deductible_applied is 0.00, including for a copay that would otherwise credit the deductible." "balance is running total deductible_applied (for deductible) or of member_responsibility (for OOP balance). Because OON thresholds are higher, OON claims can carry member's balance past in-network individual amount,and family balances past family amounts; balances are not capped at in-network amounts." Hmm OOP balances capped? OOPM maximum maybe once member reaches 7000 in-network? But OON threshold 14000. Need plan: OOPM individual(in-network) 7000, family(in-network) 14000, individual(OON) 14000. Once a member reaches OOPM plan pays 100% allowed amount. Need determine when reaches OOPM? For in-network claims maybe member's OOP balance measured against 7000? For OON maybe measured against14000? Similar to ded: A single OOPM balance? In-network threshold 7000? OON threshold14000. But need likely track member_responsibility cumulative. "Because OON thresholds are higher, OON claims can carry member's balance past the in-network individual amount, and the family balances past the family amounts; the balances are not capped at the in-network amounts." This suggests OOP balance is running total member_responsibility; OOPM threshold for OON is 14000 and for in-network is 7000? When member's OOP balance? Need apply if cumulative member_responsibility reaches relevant threshold. Need know OOPM structure for family? Family OOPM 14000 aggregate? likely if family total reaches 14000 maybe plan pays all for all? But not essential maybe no threshold reached? Need compute.
Need process all claims sequentially carefully. Could use manual tables. Need final ending accumulators for each member deductible and OOPM balances after all lines. Need final components on books for claim19, claim20 adjusted, claim25.
Need compute line by line with aggregate family deductible and OON individual thresholds.
OOP.
Let's create detailed table. Need include all lines to determine accumulators.
claim20 adjustment line23 affects accumulators remaining.
Need handle voids Claim3 and Claim6 removing credits from accumulators at adjustment/void point, and re-adjudicate? VOID just removes credits, no replacement. ADJUSTMENT removes original credits and posts corrected claim against accumulators as they stand at adjustment. Need process order.
Important "ADJUSTMENT: credits that claim generated—its deductible credit and its member responsibility—are removed from every accumulator they touched (the member's and the family's), and claim adjudicated again at corrected values against accumulators AS THEY STAND at point adjustment is processed. Claims processed between original and adjustment are NOT reprocessed; results stand as first adjudicated." So for Line23 adjustment to Claim20, remove original Claim20 deductible credit and member_resp from member A and family accumulators as they currently stand before line23; then adjudicate corrected claim20 at corrected allowed against those accumulators (post-removal?) Need order within line: "When a line is an adjustment to an earlier claim, the credits that claim generated ... are removed from every accumulator ..., and the claim is adjudicated again ... against the accumulators AS THEY STAND at the point the adjustment is processed." "AS THEY STAND at the point the adjustment is processed" perhaps after unwinding? They say remove then adjudicated against accumulators as they stand at adjustment. Need likely net effect: remove original credits, then adjudicate corrected. Yes.
For VOID line14 Claim3: remove Claim3 credits from member C and family, no replacement. Line16 Claim6 remove from A/family.
Need keep timing: All prior lines accumulated. When void remove from current accumulators at line14. That affects subsequent lines only. BUT final balances net all credits including voids. Need not adjust prior claims.
We'll track running totals after each line, including additions/removals.
We'll also need components for Claim19,20,25. For Claim20 final on books is adjusted at line23. Need compute adjusted components and also need remove original then add corrected at line23; net family totals include both (original plus corrected? Actually original was added at line20 then removed at line23 and corrected added; net final contribution is corrected only. Running accumulators after line23 should reflect corrected. For final components for claim20 use line23 corrected values.
Detailed plan mechanics:
- For in-network service, cost share:
Is subject to deductible then coinsurance 10%. But aggregate family deductible means plan pays no coinsurance for any member until total family credits reach family deductible amount. What exactly "total family credits" includes both in-network and out-of-network ded credits? Plan says "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance"; family total similarly probably sums all family members' balances. Family deductible threshold 6400 in-network? Addendum "Because OON thresholds are higher, OON claims can carry ... family balances past the family amounts; balances are not capped at in-network amounts." This says family balances can exceed family amounts but does that mean once family total reaches 6400, in-network deductible met? OON claims measured against individual OON thresholds only, family amounts don't limit OON claim. But for OON, once member's OON threshold met, coinsurance. Family aggregate not limiting OON? Addendum final: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. The credits an out-of-network claim generates still accumulate to the member's balance and to the family balance." This seems intended to handle interplay: OON claim deductible_applied based on individual OON remainder (member's own balance), not family remainder. But family deductible (aggregate) for in-network yes. OON credits count toward family total for in-network deductible? If yes, OON claim can satisfy family deductible even though not limited by family. Need yes.
- For OON service, member cost share 40% after deductible. But if family aggregate deductible not met? Could OON claim still pay coinsurance after individual OON deductible threshold, irrespective of family deductible? Addendum says OON measured against OON individual threshold only; family amounts ( in-network) do not limit OON claim. So yes, for OON claim, once member's OON deductible threshold is met, coinsurance 40% after OON deductible. But wait family aggregate for all services? This plan's Deductible says AGGREGATE — plan pays no coinsurance for any member until total family credits reach family deductible amount. Then addendum says out-of-network claims measured against OON individual thresholds only; family amounts do not limit OON. This may override aggregate for OON? Need reconcile. Let's think.
The family aggregate condition says no member reaches coinsurance until total family credits reach family deductible. For in-network, that means individual ded not used; family threshold used. For out-of-network, if family aggregate still unmet, would no coinsurance for OON too, but then OON claim measured against OON individual threshold only? It says "the out-of-network individual remainder, measured against the member's same single deductible balance." So OON claim's deductible_applied is based on individual OON remainder, not family. If family aggregate awaited, after OON deductible threshold? There is contradiction. The addendum likely designed to specify: OON claims measured against out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim. So maybe for OON claim, coinsurance begins after member's OON individual deductible, regardless family aggregate. That would mean family aggregate only for in-network claims. But plan document says aggregate all? Let's parse exact addendum from prompt:
"ACCUMULATORS (addendum to the plan document)
A claim's deductible_applied is the LESSER of its allowed amount and the room
left under the deductible threshold that applies to it:
in-network .........the smaller of the member's individual remainder and
the family remainder (embedded), or the family
remainder alone (aggregate);
out-of-network ..... the out-of-network individual remainder, measured
against the member's same single deductible balance.
Once the applicable threshold is met, deductible_applied is 0.00, including
for a copay that would otherwise credit the deductible.
A balance is the running total of deductible_applied (for a deductible) or
of member_responsibility (for an out-of-pocket balance. Because the
out-of-network thresholds are higher, out-of-network claims can carry a
member's balance past the in-network individual amount,and the family
balances past the family amounts;the balances are not capped at the
in-network amounts.
Out-of-network claims are measured against the out-of-network individual
thresholds only;the family amounts, which are in-network amounts, do not
limit an out-of-network claim.The credits an out-of-network claim generates
still accumulate to the member's balance and to the family balance."
This is explicit. For OON, applicable threshold = OON individual remainder. Family amounts do not limit. So an OON claim can have deductible_applied up to remaining OON threshold for that member, then coinsurance 40%. So family aggregate doesn't limit OON. But OON credits count toward family total and member's single balance.
The family total used to test in-network claims (aggregate family deductible) likely includes OON credits. Since credits accumulate. So after an OON claim with member C allowed 10883.95 line2, member C OON threshold 6400; her single balance? before line2 C deductible0. OON individual remainder =6400. Series? Line2 OON claim allowed >6400, so deductible_applied =6400? But "LESSER of allowed and room left under threshold" if allowed 10883.95, threshold 6400, deductible_applied=6400. Then coinsurance=40% of (10883.95-6400)=40%*4483.95=1793.58. Member_resp=6400+1793.58=8193.58. This exceeds OOPM? OOPM OON individual 14000, not reached. Family deductible? Family total gets 6400 from C. For in-network claims, family deductible aggregate threshold 6400 is now met? Wait after line2 family total=6400 exactly, so in-network deductible satisfied for all members? Plan aggregate: no coinsurance for any member until total family credits reach family deductible amount. Once family total reaches 6400, then in-network coinsurance applies for subsequent in-network claims. Thus line4 in-network urgent care: family remaining 0, deductible_applied0, coinsurance10% *255.34=25.53. This seems plausible.
But is it allowed for OON claim to contribute 6400 to family deductible, satisfying family aggregate all at once? The addendum says OON credits accumulate to family balance. Yes. So family deductible can be met via one child OON claim. This is intended maybe.
Need track OOP balances. For OON claim line2, member_resp 8193.58. OOPM for OON individual 14000, so not reached. But member_resp accumulates to member C OOP balance. Family OOP total? also accumulates. Meanwhile family OOPM 14000 maybe threshold for family? After line2 family OOP=8193.58. Is there any cap? Need apply once member/family OOP reaches threshold. The OOPM thresholds: Individual(in-network) 7000; Family(in-network) 14000; Individual(OON) 14000. Once a member reaches OOPM plan pays100%. Which threshold for line2 OON? individual OON 14000. Since member_resp=8193.58, below. Family OOPM maybe 14000, not reached. But if later family OOP reaches 14000, plan pays100% for family? Need track family OOP total based on member_responsibility. Under aggregate OOPM perhaps once family total reaches 14000, no member pays? Need plan says "Family (in-network) ... 14000.00" likely family OOPM aggregate? The OOPM structure not explicitly "AGGREGATE" but in HDHP likely family OOPM aggregate after family total? Need use "Family OOPM" maybe like family deductible? Need infer from accumulators: family_total OOP 0.00; likely compare against family OOPM. If family OOP total reaches 14000, plan pays100%? But need exact order with individual OOP? We need see i[empty response]Grader detail
json{
"reason": "response did not contain parseable JSON"
}0Claude Haiku 4.5 · Anthropic457.9s · 51,928 out | 271.5s · 30,663 out | 176.2s · 20,322 out
Reasoning · 51,460 tokens
Let me work through this ledger step by step, tracking deductible and out-of-pocket accumulators for each member and for the family.
Key facts from the plan:
- Individual in-network deductible: 3200.00
- Family in-network deductible: 6400.00
- Structure: AGGREGATE - family deductible must be satisfied before ANY member gets coinsurance
- Out-of-network individual deductible: 6400.00
- Individual in-network OOPM: 7000.00
- Family in-network OOPM: 14000.00
- Individual out-of-network OOPM: 14000.00
- In-network coinsurance: 10% member / 90% plan after deductible
- Out-of-network coinsurance: 40% member / 60% plan after deductible
- In-network and out-of-network credits accumulate to a SINGLE member deductible balance
- Preventive services (in-network) carry no cost share and move no accumulator
- Out-of-network preventive services are subject to out-of-network deductible and coinsurance
Let me process each line:
**Line 1 — Claim 1 — A (subscriber) — In-network pharmacy — Allowed: 74.87**
- Family deductible balance: 0.00, needs 6400.00
- Member A deductible balance: 0.00, needs 3200.00 (aggregate, so only family matters)
- Deductible applied: min(74.87, 6400.00) = 74.87
- After deductible: 74.87 - 74.87 = 0.00
- Coinsurance: 0.00 * 10% = 0.00
- Member responsibility: 74.87 + 0.00 = 74.87
- Plan paid: 0.00
- Member A deductible: 74.87
- Family deductible: 74.87
- Member A OOPM: 74.87
- Family OOPM: 74.87
**Line 2 — Claim 2 — C (child) — Out-of-network inpatient — Allowed: 10883.95**
Family still owes 6400.00-74.87=6325.13 toward deductible. Applying 6325.13 leaves 4558.82 remaining, subject to 40% out-of-network coinsurance.
- Coinsurance: 4558.82 × 40% = 1823.53
- Member responsibility: 6325.13 + 1823.53 = 8148.66
- Plan paid: 2735.29
- Family deductible now fully met at 6400.00
- Family OOPM running total: 74.87 + 8148.66 = 8223.53
**Line 3 — Claim 3 — C (child) — Out-of-network lab — Allowed: 967.99**
Family deductible is satisfied, but member C still has 6325.13 remaining against the 6400.00 out-of-network threshold.
Deductible applied: min(967.99, 74.87) = 74.87, closing out member C's out-of-network deductible.
Remaining 893.12 hits coinsurance at 40% = 357.25.
Member responsibility: 74.87 + 357.25 = 432.12
Plan paid: 535.87
Member C OOPM: 8580.78, Family OOPM: 8655.65
Line 4 — Claim 4 — A — In-network urgent care — Allowed: 255.34
Family deductible now satisfied, so no deductible applies here.
Coinsurance: 255.34 * 10% = 25.53
Member responsibility: 25.53, Plan paid: 229.81
Member A OOPM: 100.40, Family OOPM: 8681.18
Line 5 — Claim 5 — A — In-network ED — Allowed: 3545.18
No deductible applied (family satisfied)
Coinsurance: 3545.18 * 10% = 354.52
Plan paid: 3190.66
Member A OOPM: 454.92, Family OOPM: 9035.70
Line 6 — Claim 6 — A — In-network allergy testing — Allowed: 911.89
Family deductible: 0.00
(satisfied)
Coinsurance: 911.89 * 10% = 91.19
Plan paid: 820.70
Member A OOPM: 546.11, Family OOPM: 9126.89
Line 7 — Claim 7 — B — In-network ambulatory surgery — Allowed: 7845.50, no deductible needed, coinsurance 784.55.
Plan paid: 7060.95. Member B OOPM: 784.55, Family OOPM: 9911.44.
Line 8 — Claim 8 — D — In-network ambulatory surgery — Allowed: 6750.63, coinsurance 675.06, plan paid 6075.57. Member D OOPM: 675.06, Family OOPM: 10586.50.
Line 9 — Claim 9 — B — In-network inpatient — Allowed: 12250.27, coinsurance 1225.03, plan paid 11025.24. Member B OOPM: 2009.58, Family OOPM: 11811.53.
Line 10 — Claim 10 — D — In-network inpatient — Allowed: 12224.51, deductible already satisfied, moving to coinsurance calculation.
0.00 applied, coinsurance 1222.45, plan paid 11002.06. Member D OOPM climbs to 1897.51, Family OOPM reaches 13033.98.
Line 11 — Claim 11 — D — Out-of-network wellness visit, allowed 664.62. Since this is preventive but out-of-network, it still hits the out-of-network deductible and coinsurance rather than being covered at 100%. Checking D's out-of-network deductible balance.
Actually, hold on — I need to reconsider. The plan language specifies preventive care is only covered at 100% without cost-sharing when rendered in-network. Out-of-network preventive services don't get that special treatment.
**Line 12 — Claim 12 — B (spouse) — Out-of-network pharmacy — Allowed: 30.19**
- Member B deductible balance: 0.00, out-of-network threshold: 6400.00
- Deductible applied: min(30.19, 6400.00) = 30.19
- After deductible: 0.00
- Coinsurance: 0.00
- Member responsibility: 30.19, plan paid: 0
- Member B deductible: 30.19, OOPM: 2009.58 + 30.19 = 2039.77
- Family OOPM: 13698.60 + 30.19 = 13728.79
**Line 13 — Claim 13 — D (child) — Out-of-network screening colonoscopy — Allowed: 716.51**
- Preventive service, still subject to out-of-network deductible/coinsurance
- Member D deductible balance: 664.62, threshold 6400.00
- Deductible applied: min(716.51, 5735.38) = 716.51
After deductible, remaining allowed is 0.00, so coinsurance is 0.00. Member responsibility is the full 716.51, plan pays 0.00.
- Member D deductible: 664.62 + 716.51 = 1381.13
- Member D OOPM: 2562.13 + 716.51 = 3278.64
- Family OOPM: 13728.79 + 716.51 = 14445.30
**Line 14 — VOID of Claim 3**
Recalling Claim 3's original figures: member responsibility 432.12, plan paid 535.87, deductible applied 74.87, coinsurance 357.
Reversing these amounts:
- Member C deductible: 6400.00 - 74.87 = 6325.13
- Member C OOPM: 8580.78 - 432.12 = 8148.66
- Family deductible: 6400.00 - 74.87 = 6325.13
- Family OOPM: 14445.30 - 432.12 = 14013.18
**Line 15 — Claim 15 — A (subscriber) — Out-of-network endoscopy — Allowed: 2331.25**
Member A's deductible balance is 74.87 against an out-of-network threshold of 6400.00. Applying deductible: min(2331.25, 6325.13) = 2331.25, leaving nothing after deductible, so coinsurance is 0.00.
- Member responsibility: 2331.25
- Plan paid: 0.00
- Member A deductible: 74.87 + 2331.25 = 2406.12
- Member A OOPM: 546.11 + 2331.25 = 2877.36
- Family OOPM: 14013.18 + 2331.25 = 16344.43
**Line 16 — VOID of Claim 6**
Reversing Claim 6 (member responsibility 91.19, plan paid 820.70, deductible 0.00, coinsurance 91.19):
- Member A OOPM: 2877.36 - 91.19 = 2786.17
- Family OOPM: 16344.43 - 91.19 = 16253.24
**Line 17 — Claim 17 — E (child) — Out-of-network physical therapy — Allowed: 1373.69**
Member E has no deductible met yet, threshold 6400.00. Deductible applied: min(1373.69, 6400.00) = 1373.69, so the full amount goes to deductible with nothing remaining after.
Coinsurance: 0.00. Member responsibility: 1373.69, plan paid 0.00.
- Member E deductible: 1373.69
- Member E OOPM: 1373.69
- Family OOPM: 16253.24 + 1373.69 = 17626.93
**Line 18 — Claim 18 — C (child) — Out-of-network lab — Allowed: 593.21**
Member C deductible balance at 6325.13, threshold 6400.00. Deductible applied: min(593.21, 74.87) = 74.87. Remaining 518.34 goes to 40% coinsurance = 207.34.
- Member responsibility: 74.87 + 207.34 = 282.21
- Plan paid: 311.00
- Member C deductible now hits threshold: 6400.00
- Member C OOPM: 8148.66 + 282.21 = 8430.87
- Family OOPM: 17626.93 + 282.21 = 17909.14
**Line 19 — Claim 19 — B (spouse) — In-network urgent care — Allowed: 220.46**
Checking family deductible status next.
No accumulator changes for this claim. The preventive care section confirms in-network preventive services covered without cost share are paid at 100% and excluded from deductible, coinsurance, or copay.
Routine immunization falls into this category of ACA-mandated preventive services, so it should be treated as preventive with no cost sharing applied.
Turning to the adjustment for Claim 20 on line 23 - the allowed amount was corrected downward from 1243.12 to 745.87 due to a provider appeal after contract rate review. If this claim were preventive, the adjustment wouldn't touch deductible or OOPM figures, which seems inconsistent with a typical corrective adjustment scenario. This makes me reconsider - the claim was likely processed as non-preventive, subject to normal deductible/coinsurance rules, so I'll treat it that way.
For Line 20 itself: family deductible already satisfied, so 0.00 applied. Coinsurance at 10% of 1243.12 comes to 124.31, which becomes both member responsibility and the OOPM addition. Plan pays 1118.81. Member A's OOPM rises to 2910.48, family OOPM to 18055.50.
Line 21 for member C follows the same pattern - deductible satisfied, 10% coinsurance on 3516.29 equals 351.63, plan pays 3164.66.
Deductible applied: 0.00, coinsurance 124.31, plan paid 1118.81.
- Corrected Claim 20: allowed 745.87, coinsurance 745.87*10%=74.59, member responsibility 74.59, plan paid 671.28
Need to reverse the original 124.31 member responsibility from OOPM/deductible tracking and reapply the corrected 74.59, updating Member A's running accumulators accordingly (deductible was 2406.12, OOPM 2910. before adjustment).
Removing original claim impact: Member A OOPM 2910.48 - 124.31 = 2786.17. Adding corrected impact: 2786.17 + 74.59 = 2860.76.
For the family total: 18055.50 - 124.31 + 74.59 = 18005.78.
I should verify this against the actual sequence at Line 23 (2026-09-08) - checking what accumulators looked like right before this adjustment, particularly from Line 22.
Confirming Line 22 accumulators (2026-08-23): Member A at 2910.48, Family at 19654.63.
Recalculating properly: Member A 2910.48 - 124.31 + 74.59 = 2860.76. Family 19654.63 - 124.31 + 74.59 = 19604.91.
But something's off - the family OOPM cap is 14000.00, and 19654.63 already blows past that after Line 22. That means from Line 22 onward, the plan owes 100% coverage on all covered in-network services for every family member, per the "once OOPM is met, 100% coverage for rest of plan year" rule.
I need to redo the trace from where the family in-network OOPM actually crosses 14000.00.
After Line 10, family OOPM sits at 13033.98.
Then Line 11 involves Member D's out-of-network wellness visit (664.62 allowed). Out-of-network claims use a separate OOPM track — individual out-of-network cap is 14000.00, distinct from the in-network family cap. I need to check whether out-of-network costs count toward the in-network family OOPM at all, since the plan document separates these categories explicitly.
Given the wording, out-of-network claims are compared only against out-of-network individual limits, not family in-network limits. But the resulting cost-sharing still accrues to both the member's overall balance and the family's overall balance — meaning each member and the family likely track a single combined running total, even though which threshold applies depends on network status of the specific claim.
that OON payments do count toward both the individual's accumulator and the family total—they just aren't checked against the family's in-network threshold amount when determining if the claim itself hits a cap. So practically: OON claims get compared only to the OON individual threshold, but the resulting credits still add into both the member's running total and the family running total, presumably against separate OON family/individual limits if defined, or otherwise just tracked cumulatively.
So there are separate OOPM tracks: in-network individual (7000), in-network family (14000), and out-of-network individual (14000).
Out-of-network claims get measured only against the 14000 individual out-of-network threshold—the in-network family amount doesn't cap an out-of-network claim. But those out-of-network dollars still count toward both the member's individual balance and the family total.
This raises a question though: can a single member simultaneously have a 7000 in-network cap and a 14000 out-of-network cap? That would mean tracking two separate accumulators per member—one for in-network spend, one for out-of-network spend—each with its own threshold. Once a given threshold is hit, services within that network category become fully covered, while the other category keeps accumulating separately.
Family-level, the 14000 in-network OOPM likely serves as a ceiling on the combined in-network member responsibility across all family members.
I should check the ACCUMULATORS section for the precise definitions—specifically how deductible_applied is calculated as the lesser of the allowed amount and remaining room under the relevant threshold.
Embedded in-network deductibles use the smaller of the individual and family remainders, while out-of-network is measured solely against the individual's single deductible balance. Once a threshold is hit, deductible_applied drops to zero even for copays. Balances track running totals, and since out-of-network thresholds are higher, out-of-network claims can push balances past the in-network caps without being capped there.
This means there's likely a single member OOPM balance and single family OOPM balance combining both network types. In-network claims check against the in-network individual/family thresholds (7000/14000), while out-of-network claims check only against the out-of-network individual threshold (14000) — family thresholds don't constrain out-of-network claims.
Once a member's in-network balance hits 7000, in-network services become free; once out-of-network balance hits 14000, out-of-network services become free. The family in-network threshold (14000) stops in-network cost-sharing for everyone once reached, but out-of-network accumulation doesn't feed into that family cap.
Out-of-network dollars still add to both the individual and family running totals though — they just aren't checked against family limits, only against the individual's out-of-network cap. So a member's balance isn't capped at 7000 just because that's the in-network threshold; an out-of-network claim can push it higher, and correspondingly push the family total past 14000 too, since nothing caps these balances at the in-network figures.
Each member seems to track its own balance from zero. Hitting 7000 unlocks 100% coverage for that member's in-network services; hitting 14000 unlocks 100% for out-of-network services. Separately, the family in-network balance hitting 14000 unlocks 100% in-network coverage for everyone. So after an individual's OOPM is met, their in-network claims go to 100%, but out-of-network claims might still carry coinsurance until that separate threshold is reached.
But the plan document's phrasing—"pays 100% for the remainder of the plan year"—doesn't split by network, which is confusing given the two different dollar thresholds. Maybe a member's OOPM is met when they hit either threshold, whichever comes first, with in-network claims naturally hitting 7000 first unless the member is mostly out-of-network. Then again, out-of-network claims might be measured against a separate individual threshold entirely.
If a member accumulates $6000 in-network and then a $1000 out-of-network claim, that claim gets checked against the $14000 out-of-network limit, not combined with the in-network amount. This suggests OOPM is actually two separate tracked totals—one in-network (7000/14000 individual/family), one out-of-network (14000 individual)—each triggering 100% coverage independently once met. I'll proceed using this dual-tracking model.
Each member needs deductible balance (combined), plus separate in-network and out-of-network OOPM balances. Family-level tracking covers in-network deductible and OOPM only. Claims update only the matching network's balances—out-of-network claims never touch family in-network totals. Coinsurance drops to 0% once the relevant threshold (member in-network 7000, member out-of-network 14000, or family in-network 14000) is hit.
But the problem's variable naming ("ending_oopm_a") implies a single OOPM per member rather than split in/out-of-network balances, so I may need to reconsider this structure.
Perhaps a single member OOPM balance exists, with the applicable threshold depending on service type (7000 in-network, 14000 out-of-network), and once reached, that service type becomes fully covered. Family maintains one in-network OOPM balance with a 14000 threshold—so member in-network and out-of-network accumulators run separately, and hitting 7000 in-network shifts future in-network claims to 100% coverage.
Since output only asks for a single "ending_oopm_a" per member rather than split accounts, there's likely one combined accumulator, not two. Testing this: report the running total balance regardless of network type, but apply separate thresholds when checking coinsurance eligibility for each claim type based on that same combined number.
If a member accrues $6000 from in-network claims, their balance sits at $6000 - still below the $7000 in-network cutoff. Adding a $2000 out-of-network claim at 40% coinsurance contributes $800, pushing balance to $6800. In-network claims still apply coinsurance since $6800 < $7000.
This raises confusion about whether separate accumulators exist per network type or one shared balance. Assuming a single OOPM that hits the lower threshold (7000) first for all future 100% coverage doesn't explain why two different thresholds (7000 and 14000) would be specified at all.
Reconsidering the plan language: "Out-of-network claims are measured against the out-of-network individual thresholds only; the family amounts, which are in-network amounts, do not limit an out-of-network claim" - this suggests separate tracking, though the exact mechanism needs clarification.
Wait, the output fields include "ending_oopm_a", "ending_oopm_b", etc. plus "ending_family_oopm" — separate member and family accumulators confirmed. I'll track for each member: in-network balance (threshold 7000) and out-of-network balance (threshold 14000), plus one family in-network balance (threshold 14000). For reporting purposes, ending_oopm per member will just be the in-network figure since that's primary.
Preventive in-network stays cost-free and untouched by accumulators, but out-of-network preventive is subject to deductible/coinsurance and does count. Once a member's in-network OOPM hits 7000, further in-network care is 100% covered; same logic applies out-of-network at 14000. Family in-network OOPM maxing at 14000 presumably covers all members at 100% in-network going forward.
Testing this against Claim 1 (subscriber A, in-network pharmacy, $74.87 allowed): family and member deductibles start at 0, need to satisfy $6400. The full $74.87 applies to deductible, leaving $0 for coinsurance. Member A owes $74.87, plan pays nothing, and this amount lands in Member A's in-network OOPM tracker.
For Claim 2 (child C, out-of-network inpatient, $10883.95 allowed): family deductible has $6325.13 remaining after Claim 1. This entire remaining deductible applies, leaving $4558.82. Since C's out-of-network accumulator ($0) is below the $14000 threshold, 40% coinsurance kicks in on the remainder — $1823.53. Total member responsibility comes to $8148.66.
Plan pays $2735.29. Now family deductible is fully satisfied at $6400.00, C's out-of-network OOPM sits at $8148.66, while family in-network OOPM stays untouched at $74.87 since out-of-network claims don't count toward it.
Moving to Claim 3 (child C, out-of-network lab, $967.99 allowed): only $74.87 remains before hitting the $6400 out-of-network deductible threshold, so that amount applies to deductible, leaving $893.12 subject to further processing.
Plan paid: 229.81; Member A OOPM: 100.40; family OOPM: 100.40.
Claim 5, A — ED, allowed 3545.18. Both OOPM balances still under threshold, so coinsurance applies again.
10% of 3545.18 = 354.52 member owes, plan covers 3190.66. Updated OOPM for A and family: 454.92 each.
Claim 6, A — allergy testing, allowed 911.89. Still under limits, coinsurance 91.19 due, plan pays the remainder.
19 = 820.70, updating A and family OOPM to 546.11.
Claim 7 — B, ambulatory surgery, allowed 7845.50. B's OOPM starts fresh at 0, family at 546.11, both below caps. 10% coinsurance = 784.55 owed, plan pays 7060.95, pushing B's OOPMjson{
"claim_19_member_responsibility": 0.00,
"claim_19_plan_paid": 220.46,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 22.05,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 0.00,
"claim_25_plan_paid": 1508.35,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 150.84,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 842.12,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2039.77,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8193.58,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 2833.34,
"ending_deductible_e": 91.19,
"ending_oopm_e": 91.19,
"ending_family_deductible": 8806.12,
"ending_family_oopm": 14000.00
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 220.46,
"ok": true,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 22.05,
"ok": false,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1508.35,
"ok": true,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 150.84,
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 842.12,
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2039.77,
"ok": true,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8193.58,
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 2833.34,
"ok": false,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 91.19,
"ok": false,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 91.19,
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 8806.12,
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 14000,
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}Reasoning · 30,192 tokens
Let me work through this ledger step by step.
Plan details:
- Deductible: Individual (in-network) 3200, Family (in-network) 6400
- AGGREGATE structure: family deductible must be satisfied in full before plan pays coinsurance
- Out-of-network individual deductible: 6400
- Coinsurance: 10% member / 90% plan (in-network), 40% member / 60% plan (out-of-network)
- Individual OOPM: 7000 (in-network), 14000 (out-of-network)
- Family OOPM: 14000 (in-network)
- Preventive services in-network: 100% plan, no cost share, no accumulator movement
- Out-of-network preventive: subject to deductible and coinsurance
Key points:
1. Aggregate deductible structure: family deductible must be met first; then coinsurance applies
2. Out-of-network deductible is a separate threshold on the same member balance
3. OOPM limits apply: individual in-network 7000, family in-network 14000, individual out-of-network 14000
4. Preventive services: in-network preventive = 0 cost share; out-of-network preventive = subject to deductible and coinsurance
Let me identify preventive services:
- Line 11: Annual wellness visit, out-of-network - PREVENTIVE
- Line 13: Screening colonoscopy, no polyp removed, out-of-network - PREVENTIVE
- Line 20: Routine immunisation, in-network - PREVENTIVE
Let me process the ledger:
**Line 1 - Claim 1 - 2026-01-07 - A (subscriber)**
Service: Generic retail pharmacy fill, in-network
Allowed amount 74.87, non-preventive, goes entirely to deductible under aggregate rules.
Member owes 74.87, plan pays 0.
Updated balances: A deductible 74.87, A OOPM 0.00; family deductible 74.87, family OOPM 0.00.
**Line 2 - Claim 2 - 2026-01-17 - C (child)**
Service: In
patient admission, out-of-network, using C's individual OON deductible (6400, currently 0).
Deductible applied: min(10883.95, 6400) = 6400
Remaining allowed after deductible: 4483.95
Coinsurance 40%: 1793.58
Total member cost: 6400 + 1793.58 = 8193.58
Plan pays: 2690.37
C's deductible now maxed at 6400, OOPM balance updated to 8193.58 (typo above, should reflect actual accumulation).
Rereading the OOPM rule: out-of-network claims only measure against individual OON thresholds, not the family amounts. But credits still flow to the member's own balance and to family balance too. So family deductible increases by 6400 (74.87+6400=6474.87), and family OOPM should also accumulate since the rule says "credits...still accumulate to the member's balance and to the family balance" - meaning family OOPM does get credited despite not being the limiting factor.
Claim 3 (C, 2/1/26, out-of-network diagnostic panel): deductible already met, 967.99 × 40% coinsurance = 387.20 member owes, plan pays 580.79. C's OOPM: 1793.58 + 387.20 = 2180.78. Family deductible stays 6474.87, family OOPM stays 0.00.
Claim 4 (A, 2/15/26, urgent care in-network): allowed 255.34, need A's deductible balance.
Family deductible balance already exceeds 6400, so it's fully satisfied — deductible applied is 0.00. Coinsurance at 10% gives 25.53 member cost, plan pays 229.81. A's deductible stays 74.87, A's OOPM becomes 25.53. Family OOPM ticks up to 25.53.
Claim 5 (A, 3/1/26, ED visit in-network): allowed 3545.18, deductible remains satisfied so nothing applied there, coinsurance at 10% comes to 354.
.87
Family OOPM balance: 380.05 + 91.19 = 471.24
**Line 7 - Claim 7 - 2026-03-19 - B (spouse)**
Service: Ambulatory surgery, in-network
Network: In-network
Allowed amount: 7845.50
Family deductible satisfied already.
Coinsurance (10%): 7845.50 × 0.10 = 784.55
Plan paid: 7060.95
B OOPM balance: 784.55
Family OOPM balance: 471.24 + 784.55 = 1255.79
**Line 8 - Claim 8 - 2026-03-28 - D (child)**
Service: Ambulatory surgery, in-network
Allowed amount: 6750.63
Family deductible satisfied.
Coinsurance (10%): 6750.
63 × 0.10 = 675.06
Member responsibility: 675.06
Plan paid: 6075.57
D OOPM balance: 675.06
Family OOPM balance: 1255.79 + 675.06 = 1930.85
**Line 9 - Claim 9 - 2026-04-11 - B (spouse)**
Service: Inpatient admission, in-network
Allowed amount: 12250.27
Coinsurance (10%): 1225.03
Member responsibility: 1225.03
Plan paid: 11025.24
B OOPM balance: 784.55 + 1225.03 = 2009.58
Family OOPM balance: 1930.85 + 1225.03 = 3155.88
**Line 10 - Claim 10 - 2026-04-27 - D (child)**
Service: Inpatient admission, in-network
Allowed amount: 12224.51
Family deductible satisfied, deductible applied: 0.00
Coinsurance (10%): 1222.45
Member responsibility: 1222.45
Member owes the full 664.62 as deductible, no coinsurance since remaining allowed is 0.
Plan paid: 0.00
D deductible balance: 664.62
D OOPM balance: 1897.51
Family deductible balance: 6474.87
Family OOPM: 4378.33
Wait - checking the plan document again: "In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance."
So each member has one deductible balance fed by both in-network and out-of-network claims. Out-of-network measures against the individual 6400 threshold, while in-network measures against the family aggregate 6400. Since it's a single balance, once a member hits 6400 total, no further deductible applies to them - regardless of network type for the next claim.
But there's a wrinkle: out-of-network claims never compare against the family threshold - only their individual out-of-network threshold applies, per the plan's statement that family (in-network) amounts don't limit out-of-network accumulation.
So the picture forming is a single running balance per member, but different ceilings depending on claim type: in-network claims compare against family 6400, out-of-network claims compare against individual 6400. Once family deductible is satisfied, in-network credits stop mattering; once individual out-of-network deductible is satisfied, those credits stop separately. This means a member's total deductible spend could exceed 6400 if they hit both thresholds - up to 6400 credited toward family (in-network) and additional dollars credited toward their own out-of-network threshold.
et me check the ACCUMULATORS section: deductible_applied is the lesser of the allowed amount and the room left under the applicable threshold—in-network aggregate uses the family remainder alone, out-of-network uses the individual remainder against that same single balance (6400).
So both in-network and out-of-network claims subtract from one shared running balance per member, just measured against different thresholds. Since out-of-network thresholds are higher, those claims can carry
the balance past the in-network individual amount and past family amounts—balances aren't capped at in-network levels. Out-of-network claims only check against the individual 6400 threshold; family amounts don't limit them since those are in-network figures.
So a member's balance could exceed 6400 via out-of-network room, then further out-of-network claims measure against that already-elevated balance vs 6400 for individual out-of-network deductible.
Wait, "single member balance" phrasing suggests one running total, not two separate buckets. Let me reconsider: maybe it's one balance, and separate thresholds (individual out-of-network 6400 vs family in-network 6400) just gate when deductible stops applying for each claim type, using that same balance value.
So: start at 0. In-network claim of 1000 → balance 1000, family 1000. Out-of-network claim of 2000 → check against individual 6400
count toward the overall running total, so the balances feed into a single combined figure that tracks how much cost has accumulated.
Rethinking this, the single balance is just a running total, but I need to check limits separately: in-network claims check against the family in-network balance (capped at 6400), out-of-network claims check against the individual's out-of-network balance (capped at 6400).
So I'll track two separate deductible balances - family in-network and per-member out-of-network - each capped at 6400. For each claim, apply deductible up to min(allowed amount, remaining balance) based on which balance applies.
Restarting the ledger:
Claim 1 (A, in-network, allowed 74.87): family in-net balance goes 0→74.87, member owes 74.87, plan pays 0.
Claim 2 (C, out-of-network, allowed 10883.95): C's out-of-net balance 0→6400 (full deductible used), remaining 4483.95 gets 40% coinsurance = 1793.58, member owes 6400+1793.58=8193.58, plan pays 2690.37.
Claim 3 (C, out-of-network, allowed 967.99): deductible already met, so full coinsurance 387.20, plan pays 580.79.
Claim 4 (A, in-network, allowed 255.34): family in-net balance 74.87→330.21, member owes 255.34, plan pays 0.
This aggregate deductible applies to the family total—no member gets coinsurance on in-network claims until the full 6400 family deductible is satisfied, regardless of individual member accumulation.
Out-of-network works differently: each member has their own 6400 deductible.
Continuing with Claim 4 - A, in-network, allowed 255.34: family deductible balance now 74.87, remaining 6325.
.89
Family ded balance: 3875.39, remaining 2524.61
Ded applied: 911.89 (fully deductible)
Member resp: 911.89, Plan paid: 0.00
Family ded balance now: 4787.28
A OOPM: 0.00
**Line 7 - Claim 7 - B**
In-network, allowed 7845.50
Family ded remaining: 1612.72
Ded applied: 1612.72, member resp so far: 1612.72
Remaining allowed after ded: 6232.78, moving to coinsurance calc
6232.78 × 0.10 = 623.28 coinsurance
Total member resp: 1612.72 + 623.28 = 2236.00
Plan paid: 5609.50
Family deductible hits max at 6400.00
B OOPM: 623.28
**Line 8 - Claim 8 - D**
In-network, allowed 6750.63, deductible already met so 0 applied
Coinsurance: 675.06, plan paid 6075.57
D OOPM: 675.06
Moving to Line 9, Claim 9, member B, in-network allowed amount coming up.
- D**
Out-of-network, allowed 664.62, annual wellness visit (PREVENTIVE)
D out-of-net ded balance: 0, remaining: 6400
Out-of-network preventive still subject to deductible/coinsurance.
Ded applied: 664.62, member resp: 664.62
Plan paid: 0.00
D out-of-net ded balance: 664.62
D OOPM unchanged: 1897.51
**Line 12 - Claim 12 - B**
Out-of-network, allowed 30
ible)
Plan paid: 0.00
D out-of-net ded balance: 1381.13
D OOPM: 1897.51
**Line 14 - VOID of Claim 3 - C**
Reversing claim 3 (ded 0, member 387.20 coinsurance, plan paid 580.79):
- C out-of-net ded balance stays 6400
- C OOPM drops from 2180.78 to 1793.58
Family in-net ded remains 6400 heading into Line 15.
Family in-net OOPM totals: 2520.79
A in-net OOPM: 0.00, B: 1848.31, C out-of-net ded: 6400, C out-of-net OOPM: 1793.58, D in-net OOPM: 1897.51, D out-of-net ded: 1381.13, E out-of-net OOPM: 0.00
**Line 15 - Claim 15 - A**
Out-of-network outpatient endoscopy, allowed 2331.25. A's out-of-net ded is untouched (0/6400), so full allowed goes to deductible: 2331.25 applied, member owes 2331.25, plan pays 0.
Now void Claim 6 (A's earlier in-net claim): removes 911.89 from family in-net ded, bringing it to 5488.11. A's OOPM was never affected so stays 0.00.
State before Line 17:
Family in-net ded: 5488.11, Family in-net OOPM: 2520.79
A in-net OOPM: 0.00, A out-of-net ded: 2331.25
B in-net OOPM: 1848.31
C out-of-net ded: 6400, C out-of-net OOPM: 1793.58
D in-net OOPM: 1897.51, D out-of-net ded: 1381.13
E out-of-net OOPM: 0.00
**Line 17 - Claim 17 - E**
Out-
Physical therapy, allowed 1373.69, out-of-network. E's out-of-net ded is fresh (0), so full 1373.69 applies to deductible, member pays it all, plan pays nothing. E's ded balance becomes 1373.69, OOPM stays 0.00.
**Line 18 - Claim 18 - C**
Diagnostic lab, out-of-network, allowed 593.21. C's ded is already met (6400/6400), so 40% coinsurance applies: member owes 237.28, plan pays 355.93. C's OOPM rises to 2030.86.
**Line 19 - Claim 19 - B**
In-network urgent care visit, allowed 220.46.
Member resp: 0.00, plan paid: 1243.12
Family ded stays 5708.57, OOPM untouched since preventive doesn't accumulate.
Claim 20 components:
- deductible_applied: 0.00
- copay_amount: 0.00
- coinsurance_amount: 0.00
- member_responsibility: 0
Line 21 - Claim 21, ER visit, in-network, allowed 3516.29
Ded remaining: 691.43, so applied = 691.43
Remaining allowed after ded: 2824.86, coinsurance 10% = 282.49
Total member resp: 973.92, plan paid: 2542.37
Family ded now fully met at 5
708.57 + 691.43 = 6400.00
C's OOPM: 282.49
**Line 22 - Claim 22, E, inpatient admission**
Allowed 12475.02, family deductible already met (0 remaining)
No deductible applied, coinsurance 10% = 1247.50
Plan paid: 11227.52
E's OOPM: 1247.50
**Line 23 - adjustment coming for Claim 20, A**
Original: allowed 1243.12, no deductible/cost-share since preventive, plan paid full amount.
Corrected allowed amount is 745.87 instead — still preventive, still 100% covered, no member responsibility. Plan pays 745.87, family deductible and A's OOPM unaffected.
Checking the plan language on preventive coverage requirements though, since the covered-without-cost-share provision may need closer reading.
-net OOPM: 282.49
C out-of-net ded: 6400
C out-of-net OOPM: 2030.86
D in-net OOPM: 1897.51
D out-of-net ded: 1381.13
E in-net OOPM: 1247.50
E out-of-net ded: 1373.69
Claim 20 final: deductible 0.00, copay 0.00, coinsurance 0.00, member resp 0.00, plan paid 745.87.
Moving to claim 24, member D, in-network primary care visit, allowed 201.22.
**Line 24 - Claim 24 - D**
Family deductible already met (6400 balance, 0 remaining), no deductible applies.
Coinsurance: 201.22 × 0.10 = 20.12, member owes 20.12, plan pays 181.10.
D's in-net OOPM rises to 1917.63.
**Line 25 - Claim 25 - D**
In-network physical therapy, allowed 1508.35, deductible still satisfied.
Coinsurance: 1508.35 × 0.10 = 150.84, member resp 150.84, plan paid 1357.51.
D in-net OOPM climbs to 2068.47.
Now compiling final accumulators. For subscriber A's deductible, Claims 1, 4, 5 contributed, but Claim 6 was voided, netting 330.21. Since this plan uses an aggregate family deductible, there's no individual deductible tracking—only the shared family total matters.
But the output format requires per-member fields too: ending_deductible_a/b/etc. and ending_oopm_a/b/etc., alongside ending_family_deductible and ending_family_oopm. So I need to track each member's individual contribution toward the shared family pool, even though the family total is what actually gates cost-sharing.
For member A, in-network contributed 74.87 + 255.34 + 911.89 = 1242.10 pre-adjustment, dropping to 330.21 post-adjustment once one claim is corrected. Out-of-network contributed 2331.25 separately. The plan lists an individual in-network deductible of 3200 alongside the family's 6400 — so individual figures may just track that member's share of the aggregate, not a separate threshold.
Rereading the plan document confirms it: "There is no individual deductible under this structure" under AGGREGATE. So the listed 3200 individual amount is essentially vestigial — only the 6400 family deductible actually governs when coinsurance kicks in for any member. The 3200 might just represent what the individual would owe if the structure were embedded instead, included for reference despite being inapplicable here.
This raises the question of how to report "ending_deductible" per member. Since individuals have no separate limit in an aggregate design, does ending_deductible_a even make sense as a distinct value, or should it just mirror the family figure? Logically, tracking accumulators should show each member's remaining room toward the shared family threshold, not toward a nonexistent individual cap — so individual "ending_deductible" may simply need to reflect the family total's remaining balance at 6400.
's out-of-network deductible accumulated = 0.00 (or whatever value applies)
Also out-of-network deductibles exist separately per member: A=2331.25, B=30.19, C=6400.00 (satisfied), D=1381.13, and E needs checking too. These are individual out-of-network accumulators, distinct from the in-network family deductible.
Now for OOPM tracking—only member cost-sharing (not deductible itself) counts. Out-of-network payments count toward individual OOPM but not the family OOPM bucket.
Checking A: in-network OOPM stays 0 since only preventive care was used. Out-of-network OOPM also 0 since only deductible was paid, no coinsurance yet.
So A's running totals: in-net OOPM 0.00, out-of-net OOPM 0.00, out-of-net deductible accumulated 2331.25.
Thresholds to track against: individual in-network 7000, family in-network 14000, individual out-of-network 14000.
In-network member responsibility feeds both individual and family in-network OOPM; out-of-network responsibility only feeds individual out-of-network OOPM, separate from family in-network tracking.
For B, in-network member responsibility comes to 1612.72.
.92
C out-of-net member resp: claim 3 voided, so checking claims 2 and 18 only
- Claim 2: 6400 ded + 1793.58 coins
- Claim 18: 0 ded + 237.28 coins
Total out-of-net: 1793.58 + 237.28 = 2030.86
Ending out-of-net OOPM for C: 2030.86
D:
- In-net member resp: 675.06 + 1222.45 + 20.12 + 150.84 = 2068.47
- Out-of-net: claims 11 and 13 were deductible only, no coinsurance remaining, so 0.00
E:
- In-net member resp: 1247.50
E out-of-net: claim 17 deductible only, so 0.00
Family in-net OOPM sums to: 0.00 + 3461.03 + 973.92 + 2068.47 + 1247.50 = 7750.92
Verifying by adding individual coinsurance line items: B's 623.28 and 1225.03, C's 282.49, D's 675.06, 1222.45, 20.12, and 150.84.
84
- E claim 22: 1247.50
That totals 5446.77, not matching 7750.92 — a discrepancy from conflating coinsurance with total member responsibility.
Member responsibility should encompass deductible, coinsurance, and copay combined, not coinsurance alone, per the plan's cost-share ceiling definition. Recalculating in-network totals per member:
- A: 0 (preventive plus out-of-net claims)
- B: 1612.72 +
Family total sits at 7750.92, below the 14000 limit, so no cap triggered. Checking individuals against 7000: A=0, B=3461.03, C=973.92, D=2068.47, E=1247.50 — all under, none capped.
Ending in-net OOPM values: A=0.00, B=3461.03, C=973.92, D=2068.47, E=1247.50, Family=7750.92.
Now for out-of-net:
- A:
a" without splitting by network type, so maybe they just want the total accumulated out-of-pocket spend per member, tracked separately against whichever threshold applies as services occur.
ending_oopm_a = 0.00 (no in-net or out-of-net spend)
ending_oopm_b = 3461.03 (in-net) + 0.00 (out-of-net)
Wait, I need to reconsider family OOPM tracking. Out-of-network claims are measured against out-of-network individual thresholds only - family amounts (in-network) don't limit out-of-network claims, but credits from out-of-network claims still flow to both member and family balances.
So family OOPM should include both in-network and out-of-network member responsibility:
- In-net total: 7750.92
- Out-of-net: A=0, B=30.19, C=2030.86, D=0, E=need to check
Family OOPM = 7750.92 + 2061.05 = 9811.97
Individual member OOPMs need same treatment - combining in-net and out-of-net responsibility for each person.
For A: 0.00 (both in-net and out-of-net are 0)
For B: in-net 3461.03, out-of-net 30.19 - but these have different thresholds (7000 vs 14000), so simple addition seems wrong.
I think the running total should just be cumulative member responsibility across all claim types, checked against whichever threshold applies to that service type at time of accrual.
- ending_oopm_a = 0
- ending_oopm_b = 3491.22
- ending_oopm_c = 3004.78
- ending_oopm_d = 2068.47
- ending_oopm_e = 1247.50
- ending_family_oopm = 9811.97
Now I need to verify these against my claim-by-claim work, especially the trickier ones like claims 19, 20, and 25.
**Claim 19 - B - 2026-07-23**
Urgent care visit, in-network, allowed 220.46. Family in-net deductible before was 5708.57, leaving 691.43 remaining — so full allowed amount goes to deductible: 220.46. No coinsurance applies since remaining allowed is 0. Plan pays 0.00, B's in-net OOPM rises to 1848.31.
**Claim 20 - A - 2026-08-03json{
"claim_19_deductible_applied": 220.46,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 0.00,
"claim_19_member_responsibility": 220.46,
"claim_19_plan_paid": 0.00,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 150.84,
"claim_25_member_responsibility": 150.84,
"claim_25_plan_paid": 1357.51,
"ending_deductible_a": 2331.25,
"ending_oopm_a": 2406.12,
"ending_deductible_b": 30.19,
"ending_oopm_b": 3711.68,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 9404.78,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3449.60,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 2621.19,
"ending_family_deductible": 6400.00,
"ending_family_oopm": 21593.37
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 220.46,
"ok": false,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 0,
"ok": false,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 220.46,
"ok": false,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 150.84,
"ok": false,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1357.51,
"ok": false,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 150.84,
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2331.25,
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2406.12,
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 3711.68,
"ok": false,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 9404.78,
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3449.6,
"ok": false,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 2621.19,
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 6400,
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 21593.37,
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}Reasoning · 19,850 tokens
This is a complex plan-year ledger calculation. Let me work through this systematically.
**Plan Details:**
- Deductible: Individual (in-network) 3200.00, Family (in-network) 6400.00
- Structure: AGGREGATE (family deductible must be met before any coinsurance)
- Out-of-network individual deductible: 6400.00
- Single member deductible balance for in-network and out-of-network combined
- Coinsurance: 10% member / 90% plan (in-network), 40% member / 60% plan (out-of-network)
- OOPM: Individual (in-network) 7000.00, Family (in-network) 14000.00, Individual (out-of-network) 14000.00
- Preventive services: in-network preventive services carry no cost share
**Important Rules:**
1. Under AGGREGATE structure, no member reaches coinsurance until the family deductible is met
2. In-network and out-of-network deductible credits accumulate to a SINGLE member deductible balance, measured against 6400.00 when out-of-network
3. Preventive services in-network: no cost share, no deductible credit
4. Out-of-network preventive services: subject to out-of-network deductible and coinsurance
5. OOPM limits apply: in-network OOPM is 7000 individual / 14000 family, out-of-network is 14000 individual
6. Member cost share is calculated from allowed amount
7. Adjustments unwind prior credits and re-adjudicate at corrected values
Let me process each claim:
**Starting state:**
- All members: deductible 0.00, OOPM 0.00
- Family: deductible 0.00, OOPM 0.00
**Line 1 - Claim 1 - 2026-01-07 - A (subscriber)**
- Generic retail pharmacy fill, in-network, allowed 74.87, non-preventive
- Family deductible remaining 6400.00, Member A remaining 3200.00
- Deductible applied: min(74.87, 3200.00, 6400.00) = 74.87
- Full allowed amount absorbed into deductible, nothing left over for coinsurance since family deductible isn't met yet.
**Line 2 - Claim 2 - 2026-01-17 - C (child)**
- Inpatient admission, out-of-network, allowed 10883.95
- Out-of-network deductible individual 6400.00, coinsurance split 40% member / 60% plan
- C's remaining deductible 6400.00, family remaining after claim 1 is 6325.13
- Need to check whether in-network and out-of-network deductibles share the same combined balance per the plan rules stated.
Looking at the accumulator language: each member has a single deductible balance that both in-network and out-of-network credits feed into. In-network is aggregate (only family threshold matters, no individual cap), while out-of-network compares against the member's individual threshold of 6400.00 on that same shared balance.
So for C, out-of-network deductible applied = min(allowed, family remainder, individual out-of-network remainder) = min(10883.95, 6325.13, 6400.00) = 6325.13.
6400.00 threshold, so deductible_applied = min(10883.95, 6400.00) = 6400.00. Remaining allowed 4483.95 hits 40% coinsurance = 1793.58 member share. Total member cost: 6400.00 + 1793.58 = 8193.58, plan pays 2690.37. C's balance now 6400.00, pushing family total to 6474.87 — over the family cap, so I'll need to check that against the limit.
Checking OOPM rules again: the plan covers 100% once someone hits their max, and out-of-network claims only count against the individual out-of-network OOPM (14000.00), not the shared family in-network amounts.
For C's claim, coinsurance still accrues toward OOPM since member_responsibility tracks the out-of-pocket balance. With allowed 10883.95, deductible_applied 6400.00 leaves 4483.95 subject to 40% coinsurance = 1793.58. Total member_responsibility becomes 8193.58, plan_paid = 2690.37. Family deductible balance updates to 6474.87, and C's OOPM balance sits at 8193.58.
Next claim for C (02-01, out-of-network lab panel, allowed 967.99): deductible is already maxed at 6400.00, so no deductible applies here—full amount hits coinsurance at 40% = 387.20, with plan paying 580.79. OOPM balance climbs to 8580.78.
Then for A's urgent care visit (02-15, allowed 255.34), I need to check family deductible remaining, but 6400.00 - 6474.87 gives a negative number, which signals something's off since family deductible can't go negative.
Rereading the accumulator rules: out-of-network claims generate credits that still count toward the family balance, even though they're measured against out-of-network individual thresholds—the family amounts (in-network) don't cap or limit them. So the 6400.00 from Claim 2 legitimately adds to the family total.
Family deductible balance after claims 1-2: 74.87 + 6400.00 = 6474.87, which exceeds the 6400.00 family deductible threshold.
Since aggregate deductibles mean no member reaches coinsurance until the family amount is fully met, once that 6400.00 threshold is crossed, all subsequent in-network claims for any family member go straight to coinsurance—no more deductible applies. Out-of-network claims still get measured against the individual 6400.00 threshold separately, but any deductible_applied from them still feeds the family balance.
For Claim 4 (2026-02-15, subscriber A, urgent care, in-network, allowed 255.34): family deductible balance is already 6474.87, well past 6400.00, so the family deductible is satisfied.
ry surgery, in-network, allowed 7845.50, deductible already met so full amount to coinsurance: 784.55 member/7060.95 plan, B OOPM now 784.55.
Claim 8 for D: ambulatory surgery, allowed 6750.63, coinsurance 675.06 member/6075.57 plan, D OOPM 675.06.
Claim 9 for B: inpatient admission, allowed 12250.27, coinsurance split 1225.03/11025.24, B OOPM climbs to 2009.58.
Claim 10 for D: inpatient admission, allowed 12224.51, coinsurance 1222.45/11002.06, D OOPM rises to 1897.51.
Claim 11 for D on 2026-05-10 - annual wellness visit, out-of-network. This counts as preventive but out-of-network preventive still hits deductible and coinsurance per plan rules. D's out-of-network deductible is untouched at 0, threshold 6400. Applying 664.62 fully to deductible leaves nothing for coinsurance, so member owes the full 664.62 and plan pays nothing. D's out-of-network deductible balance becomes 664.62.
Family deductible: 6474.87 + 664.62 = 7139.49
D OOPM: 1897.51 + 664.62 = 2562.13
Claim 12 - B, out-of-network generic retail pharmacy fill, allowed 30.19. B's out-of-network deductible starts at 0, threshold 6400. Full 30.19 applies to deductible, nothing left for coinsurance - member pays 30.19, plan pays 0. B's deductible balance becomes 30.19.
Family deductible: 7139.49 + 30.19 = 7169.68
B OOPM: 2009.58 + 30.19 = 2039.77
Claim 13 - D, out-of-network screening colonoscopy without polyp removal, allowed 716.51. This is preventive but out-of-network, so still subject to deductible and coinsurance. D's out-of-network deductible balance is 664.62, threshold 6400, remaining 5735.38.
deductible_applied: min(716.51, 5735.38) = 716.51
After deductible: 0.00, coinsurance 0.00
Member_responsibility: 716.51, plan_paid: 0.00
D deductible balance: 664.62 + 716.51 = 1381.13
Family deductible: 7169.68 + 716.51 = 7886.19
D OOPM: 2562.13 + 716.51 = 3278.64
Claim 14 voids Claim 3 for C. Since Claim 3 didn't apply any deductible (0.00), unwinding only affects OOPM - removing the 387.20 member responsibility. C's deductible balance stays 6400.00, family deductible stays 7886.19, and C's OOPM drops: 3278.64 - 387.20 = 2891.44.
Claim 15 - A, out-of-network outpatient endoscopy, allowed 2331.25. A's deductible balance is 74.87, threshold 6400, remaining 6325.13.
deductible_applied: min(2331.25, 6325.13) = 2331.25 (full amount fits)
Member_responsibility: 2331.25, plan_paid: 0.00
A deductible: 74.87 + 2331.25 = 2406.12
Family deductible: 7886.19 + 2331.25 = 10217.44
A OOPM: 471.24 + 2331.25 = 2802.49
Line 16 voids Claim 6 for A, which had contributed 0.00 deductible (family already met) and 91.19 member responsibility. Unwinding: deductible balances unchanged, A's OOPM reduces to 2802.49 - 91.19 = 2711.30.
Line 17 - E, out-of-network physical therapy, allowed 1373.69. E's deductible balance 0.00, threshold 6400.
deductible_applied: min(1373.69, 6400.00) = 1373.69, fully absorbed
Member_responsibility: 1373.69, plan_paid: 0.00
Claim 19 reported: member_responsibility 22.05, plan_paid 198.41, deductible_applied 0.00, copay 0.00, coinsurance 22.05.
**Line 20 - Claim 20 - 2026-08-03 - A (subscriber)**
- Service: Routine immunisation, in-network, allowed 1243.12
- Preventive care, in-network - no cost share, doesn't touch deductible
- Deductible_applied: 0.00, coinsurance: 0.00, member_responsibility: 0.00
- Plan_paid: 1243.12
- No balance changes for A, family, or OOPM
Note: this claim gets adjusted later, so I'll need to revisit final reported values.
**Line 21 - Claim 21 - 2026-08-17 - C (child)** - Emergency department visit, in-network, allowed 3516...
Family deductible already met, so deductible_applied is 0.00. Coinsurance at 10%: 351.63, member_responsibility: 351.63, plan_paid: 3164.66. C's OOPM balance climbs to 3480.35.
**Line 22 - Claim 22 - 2026-08-23 - E (child)** - Inpatient admission, in-network, allowed 12475.02. E's remaining OOPM room is 5626.31, well above the 1247.50 coinsurance owed, so no capping needed. Deductible_applied: 0.00, member_responsibility: 1247.50, plan_paid: 11227.52. E's OOPM balance rises to 2621.19.
**Line 23 - ADJUSTMENT to Claim 20** - A provider appeal corrects the allowed amount down from 1243.12 to 745.87. Claim 20 was preventive care with zero cost share, zero deductible applied, and full plan payment of 1243.12 — none of that touched deductible or OOPM tracking. Since adjusted claims need to reflect the corrected figures on the books, I re-adjudicate Claim 20 using the new allowed amount of 745.87, still as in-network preventive immunization with no cost share.
Final components: deductible_applied 0.00, coinsurance 0.00, member_responsibility 0.00, plan_paid 745.87. Since preventive claims never touch deductible or OOPM, A's and family deductible balances remain unchanged at 2406.12 and 11591.13, and A's OOPM balance stays at 2711.30. Now I need to double check what deductible_applied actually represents — it's the lesser of the claim's allowed amount and the remaining deductible room, capturing what portion counts toward deductible before coinsurance kicks in, and it's zero whenever the deductible is already satisfied or the service is deductible-exempt like preventive care.
Copays don't exist on this plan, so copay_amount is always 0.00. Putting the pieces together: member_responsibility = deductible_applied + copay_amount + coinsurance_amount, and plan_paid = allowed_amount minus member_responsibility, with coinsurance_amount being the member's share of whatever's left after deductible and copay are subtracted from the allowed amount.
Checking against Claim 19: allowed 220.46, deductible already met, so deductible_applied=0, copay=0, coinsurance = 220.46*0.10 = 22.05, member_responsibility=22.05, plan_paid=198.41 — matches.
Moving to Claim 24 (2026-09-20, dependent D, primary care visit, allowed 201.22), I need D's running OOPM total first. Summing prior lines for D: 675.06+1222.45+664.62+716.51 = 3278.64, leaving 3721.36 of D's 7000 individual OOPM.
For this claim, deductible_applied is 0 (already met), coinsurance = 201.22*0.10 = 20.12, member_responsibility = 20.12, plan_paid = 201.22-20.12 = 181.10.
**Claim 25** (D, physical therapy, allowed 1508.35): D's OOPM balance now 3298.76, remaining 3701.24. Deductible_applied=0, coinsurance = 1508.35*0.10 = 150.84, well under remaining OOPM, so member_responsibility=150.84, plan_paid=1357.51, updating D's OOPM balance to 3449.60.
Now compiling final accumulator balances: Member A deductible 2406.12, OOPM 2711.30; Member B deductible 30.19, OOPM 2061.82; Member C deductible 640...
Continuing to Member C's OOPM 3480.35, Member D deductible 1381.13, OOPM 3449.60, Member E deductible 1373.69, OOPM 2621.19. Summing family deductible to 11591.13 and family OOPM to 14324.26, but I need to check whether out-of-network amounts should be excluded from the family OOPM total since the family limit only applies to in-network accumulation per the plan rules.
count toward family OOPM (after voids/adjustments):
- Line 1 (A): deductible only, no coinsurance yet, so N/A
- Line 4 (A): 25.53
- Line 5 (A): 354.52
- Line 6 (A): voided, so 0.00
- Line 7 (B): 784.55
- Line 8
I need to go through each line individually and check void status before summing, rather than trusting my earlier total.
22.05 = 4309.19, then +351.63 = 4660.82, +1247.50 = 5908.32, +20.12 = 5928.44, +150.84 = 6079.28.
Family OOPM comes to 6079.28, well under the 14000.00 family limit.
Now checking individual member totals. For Member A: in-network lines 4 (25.53) and 5 (354.52), with line 6 voided and line 20 preventive (both 0.00). Out-of-network has line 15 at 2331.25. So A's in-network OOPM sums to 380.05, and I need A's out-of-network OOPM next.
Actually I need to be careful here — the OOPM types are separate and shouldn't be combined. Re-checking the plan rules: once a member hits their max, the plan covers 100% for the rest of the year. There are three distinct limits: individual in-network (7000.00), family in-network (14000.00), and individual out-of-network (14000.00). In-network claims count against both the individual and family in-network limits simultaneously, and once a member's limit is reached, their responsibility drops accordingly.
For out-of-network claims, only the individual out-of-network limit applies — family limits don't affect it. So each member has two separate OOPM trackers depending on network type.
But the task field "ending_oopm_a" suggests a single value, so I likely need to sum both types together for Member A: 380.05 + 2331.25 = 2711.30. Still, I should double check whether out-of-network claims are even meant to accumulate toward OOPM under this plan's specific rules before finalizing that total.
toward OOPM.
- Line 4: coinsurance 25.53, in-network → counts toward both limits, OOPM = 25.53
- Line 5: coinsurance 354.52, in-network → OOPM = 380.05
- Line 6: voided, no change to OOPM
- Line 15: coinsurance would be 932.50 (2331.25 * 0.40), but need to check what A has already accumulated against remaining OOPM room
Actually the out-of-network OOPM is a separate track from in-network, limit 14000. A's out-of-network total = 932.50, well under 14000.
- Line 20: preventive, $0 cost-share, no change
- Final tally for A: 380.05 in-network + 932.50 out-of-network = 1312.55 total
That contradicts my earlier 2711.30 figure — need to re-examine Claim 15 carefully.
Claim 15, dated 2026-06-18, subscriber A, outpatient endoscopy, out-of-network: allowed 2331.25, all applied to deductible, member owes 2331.25 with no coinsurance since deductible absorbed the full allowed amount.
This deductible payment still counts toward OOPM even though no coinsurance applied. So A's cumulative OOPM becomes 25.53 + 354.52 + 2331.25 = 2711.30, confirming my original number.
Rechecking B: lines 7, 9, 12, 19 sum to 784.55 + 1225.03 + 30.19 + 22.05 = 2061.82.
For C, line 2 combines deductible and coinsurance: 6400.00 + 1793.58...
Wait, let me recompute C's total: 8193.58 + 237.28 + 351.63 = 8782.49. That doesn't match my earlier 3867.20 figure - I must have mishandled the voided Claim 3.
Claim 3 was voided (out-of-network), so its OOPM contribution should be zero. Recomputing: 8193.58 + 0 + 237.28 +
over with a more careful track of OOPM, starting everyone at 0.00 (A, B, C, D, E, Family). For Claim 1 on Line 1, member A's responsibility comes to 74.87.
In-network, counts toward OOPM: A rises to 74.87, family rises to 74.87.
For Line 2, Claim 2 involves C with a responsibility of 8193.58, out-of-network, which does count toward OOPM but as an out-of-network individual charge - so C rises to 8193.58 while family stays at 74.87 since out-of-network doesn't count toward the family in-network limit.
Line 3, Claim 3 for C shows 387.20 responsibility, also out-of-network.
Continuing to accumulate: C rises to 8580.78, family remains 74.87.
Then A picks up again in Lines 4-6, all in-network. Line 4 adds 25.53 (A to 100.40, family to 100.40), Line 5 adds 354.52 (A to 454.92, family to 454.92), Line 6 adds 91.19 (A to 546.11, family to 546.11).
Line 7 introduces B with 784.55, in-network - B starts at 784.55, family combines to 546.11 + 784.55.
Line 8 brings D into play at 675.06, in-network, pushing family to 2005.72. Line 9 adds another B charge of 1225.03, bringing B to 2009.58 and family to 3230.75. Line 10 adds 1222.45 to D (now 1897.51), family reaches 4453.20.
Line 11 shifts to out-of-network D at 664.62 - D climbs to 2562.13 but family stays frozen at 4453.20 since out-of-network doesn't count toward family OOPM. Line 12 is out-of-network B for 30.19, bumping B to 2039.77 while family remains unchanged at 4453.20.
Line 13 continues out-of-network D at 716.51, D reaches 3278.64, family still 4453.20.
Line 14 voids Claim 3's C charge of 387.20 - since Claim 3 was out-of-network originally, this only affects C's running total (8580.78 → 8193.58), family OOPM untouched at 4453.20.
Line 15 introduces A at 2331.25, out-of-network, bringing A to 2786.17 while family stays at 4453.20.
Line 16 voids Claim 6's A charge of 91.19 - this one was in-network, so both A (2786.17 → 2694.98) and family (4453.20 → 4361.01) get reduced.
-network: Yes
- E OOPM: 1373.69 + 1247.50 = 2621.19
- Family OOPM: 4734.69 + 1247.50 = 5982.19
**Line 23 - ADJUSTMENT to Claim 20**
- Corrected allowed drops to 745.87, but still preventive so member responsibility stays 0.00
- No OOPM impact
**Line 24 - Claim 24 - D**
- Member responsibility: 20.12, in-network
- D OOPM: 3298.76, Family OOPM: 6002.31
**Line 25 - Claim 25 - D**
- Member responsibility: 150.84, in-network
- D OOPM: 3449.60, Family OOPM: 6153.15
Tallying final OOPM: A 2694.98, B 2061.82, C 8782.49, D 3449.60, E 2621.19, Family 6153.15 - but A's number seems off, need to double check.
Tracing back, Claim 15's member responsibility was 2331.25, applied to A's balance of 454.92 before Line 15, giving 2786.17, then Line 16 voids 91.19 to land at 2694.98 - that checks out. But I previously had 471.24 as A's pre-Line 15 balance instead of 454.92, leading to a discrepancy. Need to find where that 471.24 vs 454.92 difference came from.
recalculate by tracking OOPM forward from the start:
- After Line 1: 74.87
- After Line 4: 100.40
- After Line 5: 454.92
- After Line 6: 546.11
- After Line 15: 546.11 + 2331.25 = 2877.36
- After Line 16 (void Claim 6): 2877.36 - 91.19 = 2786.17
Line 23 (adjust Claim 20) doesn't change anything since member_responsibility was already 0.00. So A ends at 2786.17.
But earlier I calculated 2694.98 - there's a discrepancy. Let me verify whether Line 1's 74.87 should actually count toward OOPM, checking the deductible/coinsurance breakdown to confirm it's legitimate member responsibility.
Confirmed: 74.87 applies. So compiling A's full contributions - Line 1 (74.87), Line 4 (25.53), Line 5 (354.52), Line 6 (91.19, later voided by Line 16), Line 15 (2331.25), Line 20 (0.00) - the total lands at 2786.17 after removing the voided amount.
Now moving to B's contributions: Line 7 (784.55), Line 9 (1225.03), Line 12 (30.19), Line 19 (22.05), summing these up next.
): 22.05
- Line 20 (A): 0.00
- Line 21 (C): 351.63
- Line 22 (E): 1247.50
- Line 24 (D): 20.12
- Line 25 (D): 150.84
- Total: 74.87 + 25.53 + 354.52 + 784.55 + 675.06 + 1225.03 + 1222.45 + 22.05 + 351.63 + 1247.50 + 20.12 + 150.84 = 6153.15
Now I need to work out deductible balances, starting with A's.
**A's deductible:** Line 1: 74.87, Line 15: 2331.25, Total: 2406.12
**B's deductible:** Line 12: 30.19
**C's deductible:** Line 2: 6400.00, Line 3: 0.00 (already at limit), Total: 6400.00
**D's deductible:** Line 11: 664.62, Line 13: 716.51, Total: 1381.13
**E's deductible:** Line 17: 1373.69
For family deductible, summing lines 1, 2, 3(voided), 12, 15, 17 gives 10209.00 - but that doesn't match my earlier calculajson{
"claim_19_member_responsibility": 22.05,
"claim_19_plan_paid": 198.41,
"claim_19_deductible_applied": 0.00,
"claim_19_copay_amount": 0.00,
"claim_19_coinsurance_amount": 22.05,
"claim_20_member_responsibility": 0.00,
"claim_20_plan_paid": 745.87,
"claim_20_deductible_applied": 0.00,
"claim_20_copay_amount": 0.00,
"claim_20_coinsurance_amount": 0.00,
"claim_25_member_responsibility": 150.84,
"claim_25_plan_paid": 1357.51,
"claim_25_deductible_applied": 0.00,
"claim_25_copay_amount": 0.00,
"claim_25_coinsurance_amount": 150.84,
"ending_deductible_a": 2406.12,
"ending_oopm_a": 2786.17,
"ending_deductible_b": 30.19,
"ending_oopm_b": 2061.82,
"ending_deductible_c": 6400.00,
"ending_oopm_c": 8782.49,
"ending_deductible_d": 1381.13,
"ending_oopm_d": 3449.60,
"ending_deductible_e": 1373.69,
"ending_oopm_e": 2621.19,
"ending_family_deductible": 11591.13,
"ending_family_oopm": 6153.15
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": 22.05,
"ok": false,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": 198.41,
"ok": false,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": 22.05,
"ok": false,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": 745.87,
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": 150.84,
"ok": false,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": 1357.51,
"ok": false,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": 0,
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": 150.84,
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": 2406.12,
"ok": true,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": 2786.17,
"ok": true,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": 30.19,
"ok": true,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": 2061.82,
"ok": false,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": 6400,
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": 8782.49,
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": 1381.13,
"ok": true,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": 3449.6,
"ok": false,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": 1373.69,
"ok": true,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": 2621.19,
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": 11591.13,
"ok": true,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": 6153.15,
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}0DeepSeek V3.2 · DeepSeek16.0s · 406 out | 16.2s · 406 out | 15.9s · 405 out
json{
"claim_19_member_responsibility": "22.05",
"claim_19_plan_paid": "198.41",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "22.05",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "150.84",
"claim_25_plan_paid": "1357.51",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "150.84",
"ending_deductible_a": "6400.00",
"ending_oopm_a": "2331.25",
"ending_deductible_b": "6400.00",
"ending_oopm_b": "8044.77",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "10883.95",
"ending_deductible_d": "6400.00",
"ending_oopm_d": "9205.27",
"ending_deductible_e": "6400.00",
"ending_oopm_e": "1373.69",
"ending_family_deductible": "6400.00",
"ending_family_oopm": "31839.93"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "22.05",
"ok": false,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "198.41",
"ok": false,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "22.05",
"ok": false,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "150.84",
"ok": false,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1357.51",
"ok": false,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "150.84",
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "6400.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "2331.25",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "6400.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "8044.77",
"ok": false,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "10883.95",
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "6400.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "9205.27",
"ok": false,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "6400.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "1373.69",
"ok": true,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "6400.00",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "31839.93",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}json{
"claim_19_member_responsibility": "22.05",
"claim_19_plan_paid": "198.41",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "22.05",
"claim_20_member_responsibility": "0.00",
"claim_20_plan_paid": "745.87",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "0.00",
"claim_25_member_responsibility": "150.84",
"claim_25_plan_paid": "1357.51",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "150.84",
"ending_deductible_a": "3200.00",
"ending_oopm_a": "3406.07",
"ending_deductible_b": "3200.00",
"ending_oopm_b": "3210.53",
"ending_deductible_c": "3200.00",
"ending_oopm_c": "4623.66",
"ending_deductible_d": "3200.00",
"ending_oopm_d": "3050.75",
"ending_deductible_e": "3200.00",
"ending_oopm_e": "2749.48",
"ending_family_deductible": "6400.00",
"ending_family_oopm": "14000.00"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "22.05",
"ok": false,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "198.41",
"ok": false,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "22.05",
"ok": false,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "745.87",
"ok": true,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "150.84",
"ok": false,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1357.51",
"ok": false,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "150.84",
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "3200.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "3406.07",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "3200.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "3210.53",
"ok": false,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "3200.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "4623.66",
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "3200.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "3050.75",
"ok": false,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "3200.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "2749.48",
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "6400.00",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "14000.00",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}json{
"claim_19_member_responsibility": "22.05",
"claim_19_plan_paid": "198.41",
"claim_19_deductible_applied": "0.00",
"claim_19_copay_amount": "0.00",
"claim_19_coinsurance_amount": "22.05",
"claim_20_member_responsibility": "74.59",
"claim_20_plan_paid": "671.28",
"claim_20_deductible_applied": "0.00",
"claim_20_copay_amount": "0.00",
"claim_20_coinsurance_amount": "74.59",
"claim_25_member_responsibility": "150.84",
"claim_25_plan_paid": "1357.51",
"claim_25_deductible_applied": "0.00",
"claim_25_copay_amount": "0.00",
"claim_25_coinsurance_amount": "150.84",
"ending_deductible_a": "6400.00",
"ending_oopm_a": "7148.29",
"ending_deductible_b": "6400.00",
"ending_oopm_b": "2843.18",
"ending_deductible_c": "6400.00",
"ending_oopm_c": "10977.87",
"ending_deductible_d": "6400.00",
"ending_oopm_d": "14598.30",
"ending_deductible_e": "6400.00",
"ending_oopm_e": "549.48",
"ending_family_deductible": "6400.00",
"ending_family_oopm": "37117.12"
}
Grader detail
json{
"fields": [
{
"field": "claim_19_member_responsibility",
"want": 0,
"got": "22.05",
"ok": false,
"present": true
},
{
"field": "claim_19_plan_paid",
"want": 220.46,
"got": "198.41",
"ok": false,
"present": true
},
{
"field": "claim_19_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_19_coinsurance_amount",
"want": 0,
"got": "22.05",
"ok": false,
"present": true
},
{
"field": "claim_20_member_responsibility",
"want": 0,
"got": "74.59",
"ok": false,
"present": true
},
{
"field": "claim_20_plan_paid",
"want": 745.87,
"got": "671.28",
"ok": false,
"present": true
},
{
"field": "claim_20_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_20_coinsurance_amount",
"want": 0,
"got": "74.59",
"ok": false,
"present": true
},
{
"field": "claim_25_member_responsibility",
"want": 0,
"got": "150.84",
"ok": false,
"present": true
},
{
"field": "claim_25_plan_paid",
"want": 1508.35,
"got": "1357.51",
"ok": false,
"present": true
},
{
"field": "claim_25_deductible_applied",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_copay_amount",
"want": 0,
"got": "0.00",
"ok": true,
"present": true
},
{
"field": "claim_25_coinsurance_amount",
"want": 0,
"got": "150.84",
"ok": false,
"present": true
},
{
"field": "ending_deductible_a",
"want": 2406.12,
"got": "6400.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_a",
"want": 2786.17,
"got": "7148.29",
"ok": false,
"present": true
},
{
"field": "ending_deductible_b",
"want": 30.19,
"got": "6400.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_b",
"want": 2039.77,
"got": "2843.18",
"ok": false,
"present": true
},
{
"field": "ending_deductible_c",
"want": 6400,
"got": "6400.00",
"ok": true,
"present": true
},
{
"field": "ending_oopm_c",
"want": 8430.86,
"got": "10977.87",
"ok": false,
"present": true
},
{
"field": "ending_deductible_d",
"want": 1381.13,
"got": "6400.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_d",
"want": 3278.64,
"got": "14598.30",
"ok": false,
"present": true
},
{
"field": "ending_deductible_e",
"want": 1373.69,
"got": "6400.00",
"ok": false,
"present": true
},
{
"field": "ending_oopm_e",
"want": 1373.69,
"got": "549.48",
"ok": false,
"present": true
},
{
"field": "ending_family_deductible",
"want": 11591.13,
"got": "6400.00",
"ok": false,
"present": true
},
{
"field": "ending_family_oopm",
"want": 17909.13,
"got": "37117.12",
"ok": false,
"present": true
}
],
"fabricated": true,
"abstained": false
}