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🏥 '''Specific stop-loss insurance''' is a policy purchased by self-funded employers and plan sponsors that reimburses them when any single participant's claims exceed a contractually defined dollar threshold during the [[Definition:Policy period | policy period]]. In the [[Definition:Self-insurance | self-insurance]] ecosystem, it serves as the primary safeguard against the financial shock of catastrophic individual losses, functioning much like a per-occurrence [[Definition:Excess of loss reinsurance | excess-of-loss]] layer in traditional [[Definition:Reinsurance | reinsurance]]. Carriers writing this coverage assess the employer's [[Definition:Claims experience | claims history]], plan design, and demographic profile to set the [[Definition:Specific deductible | specific deductible]] and calculate the [[Definition:Premium | premium]].

🔄 The mechanics begin when an employer establishes a self-funded benefit plan, typically administered by a [[Definition:Third-party administrator (TPA) | third-party administrator]]. The employer selects a specific deductible — say, $150,000 per claimant per year — and pays claims out of its own funds up to that amount. Once an individual's covered medical expenses breach the deductible, the employer submits documentation to the specific stop-loss insurer, which then reimburses the excess up to the policy's maximum benefit, often set at $1 million or $2 million per individual or structured as unlimited. Timely [[Definition:Claims reporting | claims reporting]] and [[Definition:Large claim management | large-claim management]] protocols are essential, because many policies include [[Definition:Lasering | lasering]] provisions or specific exclusions for known high-cost claimants identified at [[Definition:Underwriting | underwriting]].

📊 The value of specific stop-loss insurance extends well beyond balance-sheet protection. It enables mid-sized and large employers to capture the [[Definition:Cash flow | cash-flow]] benefits and plan-design flexibility of self-funding without exposing themselves to unbounded individual-claim risk. For [[Definition:Insurance carrier | insurers]] and [[Definition:Managing general agent (MGA) | MGAs]] operating in this space, it represents a growing market driven by rising healthcare costs and employers' desire for greater control over their [[Definition:Employee benefits | benefits]] spending. Regulators in many states treat stop-loss policies as insurance products subject to [[Definition:State insurance regulation | state licensing]] and [[Definition:Solvency | solvency]] requirements, distinguishing them from the [[Definition:Employee Retirement Income Security Act (ERISA) | ERISA]]-governed self-funded plans they protect.

'''Related concepts:'''
{{Div col|colwidth=20em}}
* [[Definition:Aggregate stop-loss]]
* [[Definition:Specific stop-loss]]
* [[Definition:Self-insurance]]
* [[Definition:Lasering]]
* [[Definition:Third-party administrator (TPA)]]
* [[Definition:Medical stop-loss]]
{{Div col end}}

Definition:Specific stop-loss insurance - Revision history

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