Agents

• HMO/EPO Certificate of Coverage
• POS Certificate of Coverage
• PPO Certificate of Coverage

• HMO NON HSA Certificate of Coverage
• HMO HSA Certificate of Coverage

• 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:

• HMO full-pay SBC
• HMO CO-90 $250 SBC
• HMO CO-80 $500 SBC
• HMO CO-80 $1,000 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 CO-60 $7,500 SBC
• HMO CO-100 $7,500 SBC
• HMO HSA CO-100 $3,000 SBC
• HMO HSA CO-100 $5,000 SBC

• 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:

• HMO full-pay SBC
• HMO CO-90 $250 SBC
• HMO CO-80 $500 SBC
• HMO CO-80 $1,000 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 CO-60 $7,500 SBC
• HMO CO-100 $7,500 SBC
• HMO HSA CO-100 $3,000 SBC
• HMO HSA CO-100 $5,000 SBC

• Wisconsin large employer group application
• Wisconsin small employer group application
• Illinois large employer group application
• Illinois small employer group application

• Wisconsin large & small group employee enrollment application
• Illinois large & small group employee enrollment application

• 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.