Documents
This packet includes forms required to enroll in Lasso Healthcare MSA.
Download 2021 Enrollment Kit (opens in a new window)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)Lasso Healthcare MSA agent sales presentation.
Download 2021 Agent Sales Presentation (opens in a new window)This booklet gives you the details about your Medicare health coverage.
Download 2021 Evidence of Coverage (opens in a new window)Members can use these Star Ratings to compare our plan’s performance to other plans.
Download 2021 Star Ratings (opens in a new window)A brief overview of benefits, eligibility, availability, and other plan information.
Download 2021 Summary of Benefits (opens in a new window)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)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)Lasso Healthcare agent Frequently Asked Questions.
Download Agent FAQ (opens in a new window)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)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)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)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 member Frequently Asked Questions.
Download Member FAQ (opens in a new window)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)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)This notice is sent to enrollees when additional information is needed to open the Medical Savings Account (MSA). Please note: due to Medicare guidelines, the time you have to set up your bank account is less than Optum Bank’s 75 day timeframe. Failure to respond to a request for information may result in the denial of your enrollment.
Download Optum Bank MSA Failed Vetting Letter (opens in a new window)Information regarding newly opened Optum Bank MSA accounts.
Download Optum Bank MSA Welcome Kit (opens in a new window)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)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)Information, rights, and responsibilities upon discontinuing enrollment.
Download Rights & Responsibilities - Disenrollment (opens in a new window)This card is sent to members to access their Lasso Healthcare MSA benefits.
Download Lasso Healthcare MSA ID Card (opens in a new window)This card is sent to members to access their MSA funds.
Download Optum Bank MSA Debit Card (opens in a new window)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)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)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)An informative booklet for new members to understand how the Lasso Healthcare MSA plan works.
Download Welcome Guide (opens in a new window)