Documents and forms
Fitness/WW®
Medical
- Prescription Drug Reimbursement Form
- Mail Order Prescription Form
| Title | Language |
|---|---|
| Care Needs Screening | English |
| Form – Allow Care Management to Obtain Protected Health Information Formulario de Autorización de PHI para Programa de Manejo de Cuidado Fòmilè Otorizasyon Jesyon Swen ESP Formulário de autorização de PHI para gestão de atendimentos |
|
| Form – Assign a Healthcare Proxy | English |
| Form – Assign an Appeals Representative | English |
| Form – Assign an Appeals Representative | English |
| Form – Assign and Revoke a Personal Representative Formulario para Designar un Representante Personal Formulário de Indicação de Representante Pessoal |
English Spanish Portuguese |
| Form – Request for Access to Information | English Spanish |
| Form – Request for Restriction of Information or Confidential Communication | English |
| Form – Request to Release Information Formulario de divulgación de información Formulário de Divulgação de Informações |
English Spanish Portuguese |
| Formulario de Autorización de Representante para Apelación | Spanish |
IMPORTANT 2023 TAX INFORMATION
WellSense QHP and ConnectorCare Members' 2023 1099-HC and 1095-B tax forms will be ready to view and download through our Member Portal.
Learn how to access them here.
This year you will receive two forms that you will need in order to complete your taxes. Below you will find relevant information about these forms.
When will I receive my 1099-HC/1095-B in the mail?
According to Federal laws, all tax documents must be postmarked no later than 01/31/2024. Therefore you should receive these forms by the end of the first week in February.
Who receives the 1099-HC form? (State)
Massachusetts residents age 18 and over who were enrolled in a QHP plan at any point in 2023.
Who receives the 1095-B form? (Federal)
- Massachusetts residents age 18 and over who were enrolled in a QHP group plan at any point in 2023.
- Massachusetts residents age 18 and over who were enrolled in QHP plan administered through HSA at any point in 2023.
Who receives the 1095-A form? (Federal)
Massachusetts residents age 18 and over who were enrolled in a QHP plan through the Connector. The Health Connector sends this form. Please call the Connector at 877-623-6765 for any questions, including duplicate requests, about this form.How are the forms used?
Members will use the 1099-HC form to complete the 2023 Massachusetts personal income tax return to indicate proof of health care coverage.
QHP Group Members and QHP members enrolled through HSA will use the 1095-B form to complete the 2023 Federal personal income tax return to indicate proof of health care coverage.
Who sends out the 1099-HC form?
WellSense will be sending out the form during the last week of January for QHP members. One form will be sent out to the subscriber for the whole family.
Who sends out the 1095-B form?
WellSense will only be sending out the 1095-B form for QHP members who were enrolled in a small group plan or in a plan administered through HSA.
Who sends out the 1095-A form?
The Health Connector will send out the 1095-A form. Please call the Health Connector at 877-623-6765 for reprints or questions about this form.
What do I do if I have not received my 1099-HC/1095-B or I do not agree with what is listed on the form?
- If you had an eligibility or demographic change, WellSense will automatically be sending updated forms at the end of February and at the end of March to the mailing address on file.
- Starting February 13, 2024 you can visit our website to download your 2023 form, to call us or email us to request a duplicate form be emailed or mailed to your address.
- If you had an eligibility or demographic change, the updated forms can be requested in the second week of March or first week of April depending on when the Health Connector processed your change.
- If you have not received your form, feel free to visit our website, https://www.wellsense.org to log into the WellSense member portal to download your form.
- If you have not registered yourself, your documents will not be available in the Member Portal until you register.
|
|
1099-HC |
1095-A |
1095-B |
|||
|
|
RECEIVE? |
SENT BY |
RECEIVE? |
SENT BY |
RECEIVE? |
SENT BY |
|
QHP Individual |
YES |
WellSense |
YES |
Connector |
NO |
- |
|
QHP Small Group |
YES |
WellSense |
NO |
- |
YES |
WellSense |
|
QHP Individual in Silver A or Silver B in 2023 |
YES |
WellSense |
NO |
- |
YES |
WellSense |
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