This packet includes forms required to enroll in 2020 Lasso Healthcare MSA.
DownloadForm 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.
DownloadAn informative booklet for new members to understand how the Lasso Healthcare MSA plan works.
Download2020 Lasso Healthcare agent sales presentation.
DownloadThis booklet gives you the details about your Medicare health care coverage from January 1 – December 31, 2020.
DownloadThis notice describes how medical information about you may be used and disclosed and how you can get access to this information.
DownloadA brief guide for providers to understand how MSA clinical access rules are the same as Original Medicare.
DownloadInformation, rights, and responsibilities upon discontinuing enrollment.
DownloadThis 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.
DownloadContact information for each State Health Insurance Assistance Program (SHIP) in our service area, which provides free help regarding health insurance to Medicare beneficiaries.
DownloadA brief overview of 2020 benefits, eligibility, availability and other plan information.
DownloadLasso Healthcare does not discriminate on the basis of race, color, national origin, sex, age, or disability.
DownloadMember application for payment consideration when payment was made directly to provider.
DownloadSample MSA Failed Vetting Letter from Optum Bank.
DownloadThis card is sent to members to access their MSA funds.
DownloadThis card is sent to members to access their Lasso Healthcare MSA benefits.
DownloadOptum Bank MSA Standard Welcome Kit.
DownloadThis form is required by CMS to be submitted by a provider who is filing a standard appeal for a denied claim.
DownloadThis form is used by providers to request a recoupment from a future remittance or to send a voluntary refund check for a claims overpayment.
DownloadThis form is used by agents to transfer a partial or full book of business to another agent.
DownloadThis form is used by members to request a change to their agent.
DownloadEarn 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.
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