Documents

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

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

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Welcome Guide
Updated: 01/01/2019
agents members

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

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

Lasso Healthcare agent sales presentation for groups.

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

Lasso Healthcare agent sales presentation for individuals.

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Agent FAQ
Updated: 10/01/2018
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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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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Member FAQ
Updated: 09/26/2018
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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2019 Provider Guide
Updated: 01/01/2019
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: 09/26/2018
members

Information, rights, and responsibilities upon discontinuing enrollment.

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Scope of Appointment
Updated: 10/03/2018
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: 10/08/2018
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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Summary of Benefits
Updated: 09/26/2018
agents members

A brief overview of 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: 01/01/2019
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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MSA 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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