Important Information on Coronavirus/COVID-19

Lasso Healthcare cares about the health and safety of our members. Please visit the CDC website for the latest information on the virus and precautions you can take to stay healthy.

Documents

Important documents detailing everything you need to know about Lasso Healthcare MSA plan.
Filter Documents by Audience
2020 Enrollment Kit
Updated: 08/18/2020
agents members

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

Download
Disenrollment Form
Updated: 02/14/20
members

Form used by members to request disenrollment from plan. From 10/15-12/7, you can join, switch or drop a Medicare health or drug plan for the following year. Generally, you can’t make changes at other times except in certain situations, such as if you move out of your plan’s service area or want to join a plan in your area with a 5-star rating.

Download
Welcome Guide
Updated: 09/01/2020
agents members

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

Download
2020 Agent Sales Presentation
Updated: 09/01/2020
agents

2020 Lasso Healthcare agent sales presentation.

Download
Agent FAQ
Updated: 10/01/2019
agents

Lasso Healthcare agent Frequently Asked Questions.

Download
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.

Download
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.

Download
Member FAQ
Updated: 10/01/2019
members

Lasso Healthcare member Frequently Asked Questions.

Download
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.

Download
Provider Guide
Updated: 07/23/2020
agents members providers

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

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

Information, rights, and responsibilities upon discontinuing enrollment.

Download
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.

Download
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
2020 Summary of Benefits
Updated: 08/18/2020
agents members

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

Download
Non-Discrimination Notice
Updated: 09/21/2020
agents members providers

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

Download
Member Reimbursement Form (Application for Payment Consideration)
Updated: 02/14/20
agents members

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

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

Sample MSA Failed Vetting Letter from Optum Bank.

Download
Optum Bank MSA Debit Card
Updated: 01/01/2019
agents members

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

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

Optum Bank MSA Standard Welcome Kit.

Download
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.

Download
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.

Download
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 - Member Requested
Updated: 10/31/2019
members

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

Download
2020 For Your Health Incentive Program
Updated: 01/17/2020
members

Earn up to $250 in gift card rewards via our 2020 For Your Health program! All members are mailed a personalized packet of instructions, activity forms and reward request forms shortly after their coverage effective date. The generic forms included in this PDF may also be used.

Download
Scroll