Small group plans

• Illinois & Wisconsin booklet/plan options
• Illinois Certificate of Coverage (Non- HSA)
• Illinois Certificate of Coverage (HSA)
• Wisconsin Certificate of Coverage (HSA & Non- HSA)

• HMO full-pay SBC
• HMO CO-90 $250 SBC
• HMO CO-80 $500 SBC
• HMO CO-80 $2,000 SBC
• HMO CO-80 $2,500 SBC
• HMO CO-80 $3,500 SBC
• HMO CO-50 $6,000 SBC
• HMO CO-60 $6,500 SBC
• HMO HSA CO-100 $3,000 SBC
• HMO HSA CO-100 $5,000 SBC

• HMO full-pay SBC
• HMO CO-90 $250 SBC
• HMO CO-80 $500 SBC
• HMO CO-80 $2,000 SBC
• HMO CO-80 $2,500 SBC
• HMO CO-80 $3,500 SBC
• HMO CO-50 $6,000 SBC
• HMO CO-60 $6,500 SBC
• HMO HSA CO-100 $3,000 SBC
• HMO HSA CO-100 $5,000 SBC

• 2022 Illinois booklet/plan options
• 2022 Illinois Certificate of Coverage
• 2022 Wisconsin booklet/plan options
• 2022 Wisconsin Certificate of Coverage

2022 small group summary of benefits and coverage (SBC) Wisconsin

• MyChart update instructions.
• 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.
• Discontinuation form.
• Change of status (fillable): Use to change member information such as your name, coverage election(s) or termination of coverage benefits. General Motors employees must contact the National Benefits Center at 800.489.4646. Forms must be signed by your employer prior to submission to MercyCare.
• 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.
• Stay healthy form (fillable): Use to request reimbursement for health and wellness activities.
  • Not available for individual or small group qualified health plans.
• Auto withdrawal form: Use to authorize MercyCare to take premiums due directly from a checking or savings account. This is limited to members who pay premiums directly to MercyCare.
• Claim form 1500.
• Grievance appeal form.
• Privacy notice.
• Covered preventive services.
• Member Benefit Guide (with Rx)
• Coordination of benefits.

• Foreign claim: direct member reimbursement
• Compound claim
• Direct member reimbursement

*Not all members receive drug plan benefits through MercyCare. If you would like to verify your prescription drug benefits, please contact your employer or MercyCare’s customer service department at 800.895.2421.