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Documents

Important documents detailing everything you need to know about Lasso Healthcare MSA plan.
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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 Annual Notice of Change
Updated: 10/01/2020
members agents providers

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

Download 2021 Annual Notice of Change (opens in a new window)
2021 Agent Sales Presentation
Updated: 10/01/2020
agents

Lasso Healthcare MSA agent sales presentation.

Download 2021 Agent Sales Presentation (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 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 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 For Your Health Incentive Program
Updated: 10/01/2020
members

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

Coming soon!

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

2020 Lasso Healthcare agent sales presentation.

Download 2020 Agent Sales Presentation (opens in a new window)
2020 Enrollment Kit
Updated: 08/18/2020
agents members

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

Download 2020 Enrollment Kit (opens in a new window)
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 2020 Evidence of Coverage (opens in a new window)
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 2020 For Your Health Incentive Program (opens in a new window)
2020 Summary of Benefits
Updated: 08/18/2020
agents members

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

Download 2020 Summary of Benefits (opens in a new window)
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 Non-Discrimination Notice (opens in a new window)
Agent FAQ
Updated: 10/01/2020
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: 09/26/2018
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: 02/14/20
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)
Member FAQ
Updated: 10/01/2020
members

Lasso Healthcare member Frequently Asked Questions.

Download Member FAQ (opens in a new window)
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 Member Reimbursement Form (Application for Payment Consideration) (opens in a new window)
Notice of Privacy Practices
Updated: 10/20/2020
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 Bank MSA Failed Vetting Letter
Updated: 01/01/2019
agents members

This notice is sent to members when additional information is needed to open the MSA account.

Download Optum Bank MSA Failed Vetting Letter (opens in a new window)
Optum Bank MSA Welcome Kit
Updated: 10/01/2020
members

Information regarding newly opened Optum Bank MSA accounts.

Download Optum Bank MSA Welcome Kit (opens in a new window)
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 Overpayment Adjustment Request Form (opens in a new window)
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 Provider Guide (opens in a new window)
Rights & Responsibilities - Disenrollment
Updated: 10/15/2019
members

Information, rights, and responsibilities upon discontinuing enrollment.

Download Rights & Responsibilities - Disenrollment (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)
Optum Bank MSA Debit Card
Updated: 01/01/2019
agents members

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

Download Optum Bank MSA Debit Card (opens in a new window)
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 Scope of Appointment (opens in a new window)
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 State Health Insurance Assistance Program (SHIP) (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)
Welcome Guide
Updated: 09/01/2020
agents members

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

Download Welcome Guide (opens in a new window)
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