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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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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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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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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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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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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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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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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