Documents and Forms
- ConnectorCare/QHP WW® Reimbursement Form
- Reembolso de WW® Reimbursement para Miembros de Qualified Health Plan y ConnectorCare
|Care Needs Screening||English|
|Form – Allow Boston Medical Center to Obtain Protected Health Information||English|
|Form – Allow Care Management to Obtain Protected Health Information||English|
|Form – Assign a Healthcare Proxy||English|
|Form – Assign an Appeals Representative (MassHealth)||English|
|Form – Assign a Personal Representative||English|
|Form – Remove a Personal Representative||English|
|Form – Request for Access to Information||English|
|Form – Request for Confidential Communication||English|
|Form – Request to Release Information||English|
|Form – Revoke Release of Information||English|
|Fòmilè Otorizasyon Jesyon Swen ESP||Haitian Creole|
|Formulário de autorização de PHI para gestão de atendimentos||Portuguese|
|Formulario de autorización de PHI para||Spanish|
|Formulario de solicitud de designación de representante personal||Spanish|
|Formulario de Autorización de PHI para Administración de la Atención||Spanish|
|Formulario de Autorización de Representante para Apelación||Spanish|
Who receives the 1099-HC form? (State)
Massachusetts residents age 18 and over who were enrolled in a Qualified Health Plan at any point in 2020.
Who receives the 1095-A form? (Federal)
Massachusetts residents age 18 and over who were enrolled in one of our Qualified Health Plans (or ConnectorCare plans) through the Massachusetts Health Connector. The Health Connector sends this form. Please call the Health Connector at 877-623-6765 for any questions about this form, including requests for extra copies.
Who receives the 1095-B form? (Federal)
- Massachusetts residents age 18 and over who were enrolled in our Qualified Health Plan as part of a group at any point in 2020.
- Massachusetts residents age 18 and over who were enrolled in our Qualified Health Plan administered through HSA at any point in 2020.
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 January 29, 2021. Therefore you should receive these forms by the end of the first week in February.
How are the forms used?
You will use the 1099-HC form to complete your 2020 State income tax return. This form shows proof of health care coverage.
If you are part of a small group plan or are enrolled in one of our Qualified Health Plans through Health Services Administrator, you will use the 1095-B form to complete your 2020 Federal income tax return. This form shows proof of health care coverage
What is WellSense’s tax ID?
WellSense’s Tax ID is 043373331.
To complete your taxes you will need your Member ID, the Tax ID, and the range of months you have been covered by us.
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 your eligibility or demographic information changed, WellSense will automatically send updated forms at the end of February and at the end of March to the mailing address on file
- If you have not received your form, please send us a request for a duplicate form by logging in to the member portal and sending us a message or contact us at 855-833-8120.
Who sends out the 1099-HC form?
WellSense will send out the 1099-HC form during the last week of January for Qualified Health Plan and ConnectorCare members. One form will be sent to the subscriber for the whole family.
Who sends out the 1095-A form?
The Massachusetts 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.
Who sends out the 1095-B form?
WellSense will only send out the 1095-B form for Qualified Health Plan members who were enrolled in a small group plan or in a plan administered through Health Services Administrator.
*Please see the current year's Qualified Health Plan Evidence of Coverage and Schedule of Benefits for specific information on each plan, or additional information including which benefits, services and medications are covered or non-covered on our plan- and any restrictions or guidelines we must follow before providing them. You can find doctors and hospitals in our network here, see our privacy practices, and learn how we make sure you get the right care at the right time with our Utilization Management policy.