Large group documents
Small group documents
- 2021 Wisconsin and Illinois booklet/plan options
- 2022 Wisconsin and Illinois booklet/plan options
- 2021 Wisconsin Certificate of Coverage
- 2022 Wisconisn Certificate of Coverage
- QHP Formulary 4-tier
- Forms and documents
Summary of benefits and coverage (SBC): Wisconsin
2022:
- HMO full-pay SBC
- HMO CO-90 $250 SBC
- HMO CO-80 $500 SBC
- HMO CO-80 $1,500 SBC
- HMO CO-80 $2,500 SBC
- HMO CO-80 $3,500 SBC
- HMO CO-50 $5,000 SBC
- HMO CO-60 $6,500 SBC
- HMO HSA CO-100 $3,000 SBC
- HMO HSA CO-100 $5,000 SBC
2021:
- 2021 Illinois Certificate of Coverage
- 2022 Illinois Certificate of Coverage
- QHP Formulary 4-tier
- Forms and documents
Summary of benefits and coverage (SBC): Illinois
2022:
- HMO full-pay SBC
- HMO CO-90 $250 SBC
- HMO CO-80 $500 SBC
- HMO CO-80 $1,500 SBC
- HMO CO-80 $2,500 SBC
- HMO CO-80 $3,500 SBC
- HMO CO-50 $5,000 SBC
- HMO CO-60 $6,500 SBC
- HMO HSA CO-100 $3,000 SBC
- HMO HSA CO-100 $5,000 SBC
2021:
Employer forms
- Out of Area Dependent Coverage Form- Certain Large Group Members only- Check “My Plan Documents” to see if you are eligible for this coverage
- Change of status (fillable).
- Member benefit guide.
- Coordination of benefits.
- Auto withdrawal form (fillable).
- Employer handbook: Administrative guide.
- Provider appeal form.
- Grievance appeal form.
- Claim form 1500.
- Transition of care request: If you are newly switching insurance to MercyCare and are undergoing a current treatment, or late in your pregnancy, complete this form and fax to MercyCare for review by our utilization staff and medical director.
- Personal health information (PHI) release form (fillable): Use when a member would like MercyCare to provide personal health information to a third party. Examples of this include available benefits or claims information.
- Wellness Incentive Program form (Only available to Illinois large groups).
- Stay healthy form (fillable): Use to request reimbursement for health and wellness activities.
- Not available for individual or small group qualified health plans (QHP’s).
- Privacy notice.
- Covered preventive services.
- Dilated retinal eye exam communication form.