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Documents

Important documents detailing everything you need to know about the Lasso Healthcare MSA plan.
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2023 Annual Notice of Change - Growth MSA
Updated: 10/01/2022
members providers

This document provides existing Lasso Healthcare Growth MSA members with the changes for the upcoming benefit year.

Download 2023 Annual Notice of Change - Growth MSA (opens in a new window)
2023 Annual Notice of Change - Growth Plus MSA
Updated: 10/01/2022
members providers

This document provides existing Lasso Healthcare Growth Plus MSA Members with the changes for the upcoming benefit year.

Download 2023 Annual Notice of Change - Growth Plus MSA (opens in a new window)
2023 Evidence of Coverage
Updated: 10/01/2022
members

This booklet gives you the details about your Medicare health coverage.

Download 2023 Evidence of Coverage (opens in a new window)
2023 Lasso Healthcare Rewards Program Kit
Updated: 2/20/2023
members

Three simple activities, three opportunities to earn rewards with the Lasso Healthcare Rewards Program! All members are mailed a rewards program kit annually. A digital version of this kit may also be downloaded to fill out electronically and print at home.

Download 2023 Lasso Healthcare Rewards Program Kit (opens in a new window)
2023 Star Ratings
Updated: 10/15/2022
members providers

Lasso Healthcare MSA Star Ratings.

Download 2023 Star Ratings (opens in a new window)
2023 State Health Insurance Assistance Program (SHIP)
Updated: 10/01/2022
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.

Download 2023 State Health Insurance Assistance Program (SHIP) (opens in a new window)
2023 Summary of Benefits
Updated: 03/14/2023
members

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

Download 2023 Summary of Benefits (opens in a new window)
Agent of Record (AOR) Change Request Form - Member Requested
Updated: 10/01/2022
members

This form is used by members to request a change to their agent.

Download Agent of Record (AOR) Change Request Form - Member Requested (opens in a new window)
Authorization to Use/Disclose PHI
Updated: 07/06/2023
members providers

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

Download Authorization to Use/Disclose PHI (opens in a new window)
CMS Appointment of Representative Form
Updated: 10/01/2022
members

Form to be used by member to appoint someone to act on their behalf.

Download CMS Appointment of Representative Form (opens in a new window)
Guide to Sharing Information
Updated: 08/29/2022
members

This Guide provides information on the use of third-party applications to access your health information and key considerations you should make before you choose to allow access to a third-party.

Download Guide to Sharing Information (opens in a new window)
Member FAQ
Updated: 04/04/2023
members

Lasso Healthcare member Frequently Asked Questions.

Download Member FAQ (opens in a new window)
Member Reimbursement Form (Application for Payment Consideration)
Updated: 05/31/2022
members

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

Download Member Reimbursement Form (Application for Payment Consideration) (opens in a new window)
Non-Discrimination Notice
Updated: 10/01/2022
members providers

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

Download Non-Discrimination Notice (opens in a new window)
Notice of Privacy Practices
Updated: 10/01/2022
members providers

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

Download Notice of Privacy Practices (opens in a new window)
Overpayment Adjustment Request Form
Updated: 10/01/2022
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.

Download Overpayment Adjustment Request Form (opens in a new window)
Rights & Responsibilities - Disenrollment
Updated: 10/01/2022
members

Information, rights, and responsibilities upon discontinuing enrollment.

Download Rights & Responsibilities - Disenrollment (opens in a new window)
Waiver of Liability
Updated: 10/01/2022
providers

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

Download Waiver of Liability (opens in a new window)
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