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Documents

Important documents detailing everything you need to know about the Lasso Healthcare MSA plan.
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2022 Annual Notice of Change - Growth MSA
Updated: 10/01/2021
members agents providers

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

Download 2022 Annual Notice of Change - Growth MSA (opens in a new window)
2022 Annual Notice of Change - Growth Plus MSA
Updated: 10/01/2021
members agents providers

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

Download 2022 Annual Notice of Change - Growth Plus MSA (opens in a new window)
2022 Enrollment Kit
Updated: 10/15/2021
agents members

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

Download 2022 Enrollment Kit (opens in a new window)
2022 Evidence of Coverage
Updated: 10/01/2021
agents members providers

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

Download 2022 Evidence of Coverage (opens in a new window)
2022 Lasso Healthcare Rewards Program Kit
Updated: Coming Soon
members

Three simple activities, three opportunities to earn rewards with the Lasso Healthcare Rewards Program! All members are mailed a personalized packet of instructions, activity forms and reward request forms. You may also download the digital version of this kit to fill out electronically and print at home.

Coming Soon!

2022 Sales Presentation
Updated: 10/15/2021
agents members

Lasso Healthcare MSA sales presentation.

Download 2022 Sales Presentation (opens in a new window)
2022 Star Ratings
Updated: 10/15/2021
agents members providers

Members can use these Star Ratings to compare our plan’s performance to other plans.

Download 2022 Star Ratings (opens in a new window)
2022 State Health Insurance Assistance Program (SHIP)
Updated: 10/01/2021
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 2022 State Health Insurance Assistance Program (SHIP) (opens in a new window)
2022 Summary of Benefits
Updated: 10/01/2021
agents members

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

Download 2022 Summary of Benefits (opens in a new window)
2022 Welcome Guide
Updated: 10/01/2021
agents members

An informative booklet for new members to understand how the Lasso Healthcare MSA plan works.

Download 2022 Welcome Guide (opens in a new window)
2021 Enrollment Kit
Updated: 10/01/2020
agents members

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

Download 2021 Enrollment Kit (opens in a new window)
2021 Evidence of Coverage
Updated: 10/01/2020
agents members providers

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

Download 2021 Evidence of Coverage (opens in a new window)
2021 Lasso Healthcare Rewards Program Kit
Updated: 02/16/2021
members

Three simple activities, three opportunities to earn rewards with the Lasso Healthcare Rewards Program! All members are mailed a personalized packet of instructions, activity forms and reward request forms. You may also download the digital version of this kit to fill out electronically and print at home.

Download 2021 Lasso Healthcare Rewards Program Kit (opens in a new window)
2021 Sales Presentation
Updated: 10/01/2020
agents members

Lasso Healthcare MSA sales presentation.

Download 2021 Sales Presentation (opens in a new window)
2021 Star Ratings
Updated: 10/15/2020
agents members providers

Members can use these Star Ratings to compare our plan’s performance to other plans.

Download 2021 Star Ratings (opens in a new window)
2021 State Health Insurance Assistance Program (SHIP)
Updated: 09/21/2020
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 2021 State Health Insurance Assistance Program (SHIP) (opens in a new window)
2021 Summary of Benefits
Updated: 10/01/2020
agents members

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

Download 2021 Summary of Benefits (opens in a new window)
2021 Welcome Guide
Updated: 09/01/2020
agents members

An informative booklet for new members to understand how the Lasso Healthcare MSA plan works.

Download 2021 Welcome Guide (opens in a new window)
Agent FAQ
Updated: 09/14/2021
agents

Lasso Healthcare agent Frequently Asked Questions.

Download Agent FAQ (opens in a new window)
Agent of Record (AOR) Change Request Form - Agent Requested
Updated: 10/31/2019
agents

This form is used by agents to transfer a partial or full book of business to another agent.

Download Agent of Record (AOR) Change Request Form - Agent Requested (opens in a new window)
Agent of Record (AOR) Change Request Form - Member Requested
Updated: 10/31/2019
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: 09/28/2021
agents 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)
Disenrollment Form
Updated: 08/11/2021
members

This form is used by members to request disenrollment. Members may disenroll only during AEP (10/15-12/7) or other limited circumstances.

Download Disenrollment Form (opens in a new window)
Guide to Sharing Information
Updated: 07/01/2021
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)
Lasso Healthcare MSA ID Card
Updated: 09/01/2020
agents members providers

This card is sent to members to access their Lasso Healthcare MSA benefits.

Download Lasso Healthcare MSA ID Card (opens in a new window)
Member FAQ
Updated: 09/28/2021
members

Lasso Healthcare member Frequently Asked Questions.

Download Member FAQ (opens in a new window)
Member Reimbursement Form (Application for Payment Consideration)
Updated: 10/06/2021
agents 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: 10/01/2021
agents 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: 07/01/2021
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.

Download Notice of Privacy Practices (opens in a new window)
Optum Financial MSA Debit Card
Updated: 10/01/2021
agents members

This card is sent to members to access their MSA funds.

Download Optum Financial MSA Debit Card (opens in a new window)
Optum Financial MSA Failed Vetting Letter
Updated: 10/11/2021
agents members

This notice is sent to enrollees when additional information is needed to open the medical savings account. Please note: due to Medicare guidelines, the time you have to set up your bank account is less than Optum Financial’s 75-day timeframe. Failure to respond to a request for information may result in the denial of your enrollment.

Download Optum Financial MSA Failed Vetting Letter (opens in a new window)
Optum Financial MSA Welcome Kit
Updated: 10/01/2021
members

Information regarding newly opened Optum Financial medical savings accounts.

Download Optum Financial MSA Welcome Kit (opens in a new window)
Overpayment Adjustment Request Form
Updated: 08/26/2021
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)
Provider Guide
Updated: 10/01/2021
agents members providers

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

Download Provider Guide (opens in a new window)
Rights & Responsibilities - Disenrollment
Updated: 10/01/2021
members

Information, rights, and responsibilities upon discontinuing enrollment.

Download Rights & Responsibilities - Disenrollment (opens in a new window)
Scope of Appointment
Updated: 10/01/2021
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.

Download Scope of Appointment (opens in a new window)
Waiver of Liability
Updated: 11/24/2020
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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