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🛡️ '''Specific stop loss''' is a form of [[Definition:Stop loss insurance | stop loss]] coverage used primarily in [[Definition:Self-insurance | self-insured]] or [[Definition:Self-funded plan | self-funded]] employee benefit arrangements that caps the amount a plan sponsor must pay for any single covered individual's [[Definition:Claims | claims]] during a defined contract period. Once an individual claimant's eligible expenses exceed a predetermined threshold — known as the specific [[Definition:Attachment point | attachment point]] or specific deductible — the stop loss [[Definition:Insurance carrier | carrier]] reimburses the excess up to the policy's limits. This mechanism protects the plan sponsor from catastrophic individual losses, such as those arising from major surgical procedures, transplant cases, premature births, or high-cost specialty pharmaceutical regimens, while the sponsor retains responsibility for routine and predictable claim costs below the attachment point.

⚙️ In practice, a plan sponsor selects an attachment point — commonly ranging from $50,000 to several hundred thousand dollars per individual, depending on the group's size, risk appetite, and premium budget — and the stop loss insurer prices the coverage based on the group's demographics, claims history, and industry profile. The specific stop loss policy operates alongside, but distinct from, [[Definition:Aggregate stop loss | aggregate stop loss]] coverage, which limits total plan-wide claims rather than individual claims. When a participant's claims breach the specific attachment point during the contract year, the plan sponsor files a reimbursement claim with the stop loss carrier, typically supported by detailed [[Definition:Claims data | claims documentation]]. The [[Definition:Underwriting | underwriting]] of specific stop loss requires careful evaluation of [[Definition:Large loss | large-loss]] frequency and severity trends, and insurers often apply [[Definition:Lasering | lasering]] — setting a higher individual attachment point or excluding coverage for known high-cost claimants — to manage adverse selection.

📊 Specific stop loss has become an increasingly important product as more employers — particularly mid-market companies — move away from fully insured group health plans in favor of self-funded arrangements that offer greater flexibility and potential cost savings. The product's relevance has intensified alongside the rising prevalence of high-cost therapies, including cell and gene treatments that can carry price tags in the millions of dollars per patient. [[Definition:Managing general underwriter (MGU) | MGUs]] and specialized [[Definition:Third-party administrator (TPA) | TPAs]] play central roles in this market, often packaging stop loss coverage together with plan administration and [[Definition:Pharmacy benefit management | pharmacy benefit management]] services. While the market is most developed in the United States, where employer-sponsored health coverage is a dominant feature of the healthcare system, analogous risk-transfer mechanisms exist in other jurisdictions where large employers or public entities self-fund medical benefit obligations.

'''Related concepts:'''
{{Div col|colwidth=20em}}
* [[Definition:Aggregate stop loss]]
* [[Definition:Self-funded plan]]
* [[Definition:Attachment point]]
* [[Definition:Lasering]]
* [[Definition:Excess of loss reinsurance]]
* [[Definition:Third-party administrator (TPA)]]
{{Div col end}}

Definition:Specific stop loss - Revision history

PlumBot: Bot: Creating new article from JSON