Documents

Important documents detailing everything you need to know about Lasso Healthcare MSA plan.
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2019 Enrollment Kit
Updated: 01/01/2019
agents members

This packet includes forms required to enroll in Lasso Healthcare MSA.

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2020 Enrollment Kit
Updated: 10/01/2019
agents members

This packet includes forms required to enroll in 2020 Lasso Healthcare MSA.

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2019 Welcome Guide
Updated: 01/01/2019
agents members

2019 Welcome Guide for the Lasso Medicare Medical Savings Account (MSA).

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2020 Welcome Guide
Updated: 10/31/2019
agaents members

2020 Welcome Guide for the Lasso Medicare Medical Savings Account (MSA).

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2019 Agent Sales Presentation: Group
Updated: 10/01/2018
agents

2019 Lasso Healthcare agent sales presentation for groups.

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2019 Agent Sales Presentation: Individual
Updated: 10/01/2018
agents

Lasso Healthcare agent sales presentation for individuals.

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2020 Agent Sales Presentation
Updated: 10/01/2019
agents

2020 Lasso Healthcare agent sales presentation.

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Agent FAQ
Updated: 10/01/2019
agents

Lasso Healthcare agent Frequently Asked Questions.

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Authorization to Use/Disclose PHI
Updated: 09/26/2018
agents members providers

Form to allow member to designate someone else to be their authorized representative.

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2019 Evidence of Coverage
Updated: 09/26/2018
agents members

This booklet gives you the details about your Medicare health care coverage from January 1 - December 31, 2019.

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2020 Evidence of Coverage
Updated: 10/01/2019
agents members providers

This booklet gives you the details about your Medicare health care coverage from January 1 – December 31, 2020.

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Member FAQ
Updated: 10/01/2019
members

Lasso Healthcare member Frequently Asked Questions.

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Notice of Privacy Practices
Updated: 09/26/2018
agents members providers

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

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Provider Guide
Updated: 10/01/2019
agents members providers

A brief guide for providers to understand how MSA clinical access rules are the same as Original Medicare.

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Rights & Responsibilities - Disenrollment
Updated: 10/15/2019
members

Information, rights, and responsibilities upon discontinuing enrollment.

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Scope of Appointment
Updated: 10/01/2019
agents

This document is required for an agent to present a Medicare Advantage Plan prior to a one-on-one meeting whether face to face or over the phone.

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State Health Insurance Assistance Program (SHIP)
Updated: 10/01/2019
members

Contact information for each State Health Insurance Assistance Program (SHIP) in our service area, which provides free help regarding health insurance to Medicare beneficiaries.

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2019 Summary of Benefits
Updated: 09/26/2018
agents members

A brief overview of 2019 benefits, eligibility, availability and other plan information.

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2020 Summary of Benefits
Updated: 10/01/2019
agents members

A brief overview of 2020 benefits, eligibility, availability and other plan information.

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1557 (Non-Discrimination Notice)
Updated: 01/01/2019
agents members providers

Lasso Healthcare does not discriminate on the basis of race, color, national origin, sex, age, or disability.

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Member Reimbursement Form (Application for Payment Consideration)
Updated: 10/01/2019
agents members

Member application for payment consideration when payment was made directly to provider.

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MSA Failed Vetting Letter
Updated: 01/01/2019
agents members

Sample MSA Failed Vetting Letter from Optum Bank.

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Sample Optum Bank Debit Card
Updated: 01/01/2019
agents members

Sample Optum Bank Debit Card.

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Sample Lasso Healthcare MSA ID Card
Updated: 01/01/2019
agents members providers

Sample Lasso Healthcare MSA ID Card.

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Optum Bank MSA Account Standard Welcome Kit
Updated: 01/01/2019
members

Optum Bank MSA Standard Welcome Kit.

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Waiver of Liability
Updated: 02/04/2019
providers

This form is required by CMS to be submitted by a provider who is filing a standard appeal for a denied claim.

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2019 Gift Card Redemption Instructions
Updated: 02/26/2019
members

As part of the For Your Health program, the instructions provide members the steps to be taken to receive their reward for each activity completed.

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2019 Health Survey Form
Updated: 02/26/2019
members

As part of the For Your Health program, the health survey is to be completed by members and the responses will assist Lasso Healthcare with supporting members on their healthcare journey.

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2019 Health Survey Gift Card Form
Updated: 02/26/2019
members

As part of the For Your Health program, the form is used by members to select their reward upon completion and submission of the health survey form.

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2019 Labs Incentive Certification Form
Updated: 02/26/2019
members

As part of the For Your Health program, the labs incentive form is to be completed by the member and their medical or lab provider after lab work.

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2019 Labs Gift Card Form
Updated: 02/26/2019
members

As part of the For Your Health program, the form is used by members to select their reward upon completion and submission of the lab incentive certification form.

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2019 Annual Wellness Visit Certification Form
Updated: 02/26/2019
members

As part of the For Your Health program, the annual wellness visit form is to be completed by the member and their provider after an annual wellness visit.

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2019 Annual Wellness Visit Gift Card Form
Updated: 02/26/2019
members

As part of the For Your Health program, the form is used by members to select their reward upon completion and submission of the annual wellness visit certification form.

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Overpayment Adjustment Request Form
Updated: 04/25/2019
providers

This form is used by providers to request a recoupment from a future remittance or to send a voluntary refund check for a claims overpayment.

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Annual Notice of Change: Region 1 to Region 1
Updated: 10/01/2019
members

A description of deductible, deposit and member responsibility amount changes that become effective January 1, 2020. For members in 2019 Region 1 areas that remain Region 1 in 2020.

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Annual Notice of Change: Region 1 to Region 2
Updated: 10/01/2019
members

A description of plan benefit package/service area and deductible, deposit and member responsibility amount changes that become effective January 1, 2020. For members in 2019 Region 1 areas that are changing to Region 2 in 2020.

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Annual Notice of Change: Region 1 to Region 3
Updated: 10/01/2019
members

A description of plan benefit package/service area and deductible, deposit and member responsibility amount changes that become effective January 1, 2020. For members in 2019 Region 1 areas that are changing to Region 3 in 2020.

Download
Annual Notice of Change: Region 2 to Region 1
Updated: 10/01/2019
members

A description of plan benefit package/service area and deductible, deposit and member responsibility amount changes that become effective January 1, 2020. For members in 2019 Region 2 areas that are changing to Region 1 in 2020.

Download
Annual Notice of Change: Region 2 to Region 2
Updated: 10/01/2019
members

A description of deductible, deposit and member responsibility amount changes that become effective January 1, 2020. For members in 2019 Region 2 areas that remain Region 2 in 2020.

Download
Annual Notice of Change: Region 2 to Region 3
Updated: 10/01/2019
members

A description of plan benefit package/service area and deductible, deposit and member responsibility amount changes that become effective January 1, 2020. For members in 2019 Region 2 areas that are changing to Region 3 in 2020.

Download
Annual Notice of Change: Region 3 to Region 1
Updated: 10/01/2019
members

A description of plan benefit package/service area and deductible, deposit and member responsibility amount changes that become effective January 1, 2020. For members in 2019 Region 3 areas that are changing to Region 1 in 2020.

Download
Annual Notice of Change: Region 3 to Region 2
Updated: 10/01/2019
members

A description of plan benefit package/service area and deductible, deposit and member responsibility amount changes that become effective January 1, 2020. For members in 2019 Region 3 areas that are changing to Region 2 in 2020.

Download
Annual Notice of Change: Region 3 to Region 3
Updated: 10/01/2019
members

A description of deductible, deposit and member responsibility amount changes that become effective January 1, 2020. For members in 2019 Region 3 areas that remain Region 3 in 2020.

Download
Agent on Record (AOR) Change Form – Agent Change Request Form
Updated: 10/31/2019
agents

Form to transfer a partial or full book of business to another agent.

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Agent on Record (AOR) Change Form – Member Request Form
Updated: 10/31/2019
members

Form to make a change to the agent associated with a member record.

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