MercyCare Health Plans

What MercyCare Health Plans does

MercyCare Health Plans is a private, for-profit health insurance company founded in 1994 and headquartered in Janesville, Wisconsin, operating as a subsidiary of the Mercyhealth integrated health system. The company offers a full portfolio of health plan products — Qualified Health Plans on HealthCare.gov and the Illinois state exchange (organized by Bronze, Silver, and Gold metal tiers), direct-purchase individual and family plans, small and large employer group plans (including the MercyCare Premier large-group product for Illinois), Medicare Supplement (Medigap) plans, and Wisconsin Medicaid/BadgerCare Plus managed care — serving members across Northern Illinois and Southern Wisconsin in more than 50 communities.

The underlying technology stack is built on Epic electronic health records integrated with the MyChart patient portal for member self-service, video visits, and prescription management, with HL7 FHIR R4 Patient Access and Provider Directory APIs deployed to satisfy CMS interoperability mandates. Supporting integrations include Navitus Health Solutions for pharmacy benefit management, HealthSparq for provider search, WISHIN for Wisconsin statewide health information exchange, PricePoint for hospital price transparency, and Change Healthcare InterQual for clinical criteria in utilization management. The network is anchored by Mercyhealth's seven hospitals and 85-plus primary and specialty care facilities staffed by 800-plus physicians.

MercyCare generates revenue through recurring monthly health insurance premiums across its four product lines, distributed via a sales-led go-to-market that combines a dedicated direct employer sales team, insurance agents (with HealthSherpa as an enrollment channel), Health Insurance Marketplace listings, and provider-driven referrals within the Mercyhealth network. The company is NCQA-accredited, earned a 4.5 out of 5 star NCQA rating for commercial lines in 2024, and received the 2024 Press Ganey Human Experience Pinnacle of Excellence Award, placing it in the top 5% of health plans nationwide for member experience.

Name

MercyCare Health Plans

Legal name

MercyCare Health Plans

Website

https://mercycarehealthplans.com

Company type

Private

Founded year

1994

Operating status

Operating

Headcount range

501–1,000 employees

Short description

MercyCare Health Plans is a private regional health insurer founded in 1994, offering Marketplace, employer group, Medicare Supplement, and Medicaid plans across Northern Illinois and Southern Wisconsin as part of the Mercyhealth integrated health system.

Ownership category

akta.pro rank

Product category

Health Insurance

NAICS

Health Care and Social Assistance (62)

SIC

Hospital & Medical Service Plans (6324)

akta.pro primary industry

Integrated Physical-Behavioral-Social Care (Whole-Person) Medicaid Plans (HLAEAEAI)

akta.pro secondary industry

Medigap Member Support & Care Navigation (Advocacy/Concierge) (HLAEADAH)

Keywords

• Health insurance plans
• Managed care services
• Medicare supplement plans
• Employer group coverage
• Medicaid managed care

Headquarters

HQ city

Janesville

HQ country

United States

HQ region

North America

Offices1 record

Markets served

GTM type

B2B and B2C

Offering type

Services

Cost components

Personnel, Operations, Technology or R&D, Marketing or Sales, Infrastructure

Revenue model

1. Health Insurance Premiums: MercyCare generates revenue through health insurance premiums collected from members. Plans include Marketplace individual/family plans, employer group plans, Medicare supplement plans, and Medicaid/BadgerCare plans. Premium revenue is the primary source of funding for healthcare services rendered to members.

Pricing tiers

Go-to-market motion2 records

Distribution channels4 records

Marketing channels6 records

Core offering

MercyCare Health Plans is a regional health insurance issuer offering individual and family Marketplace and direct plans, employer-sponsored group plans, Medicare Supplement (Medigap) plans, and Wisconsin Medicaid/BadgerCare Plus managed care to residents of Northern Illinois and Southern Wisconsin. Plans are delivered through HMO and PPO network structures that leverage MercyCare's vertical integration with the Mercyhealth system of 7 hospitals and 85+ care facilities. Members access services via the Epic-powered MyChart portal, FHIR-based APIs for third-party data access, and complementary pharmacy, telehealth, and wellness programs.

Product overview

MercyCare Health Plans operates as a health insurance provider offering a comprehensive portfolio of health insurance products and digital health tools. The core product portfolio includes Marketplace and direct-purchased individual/family plans (organized by metal levels), employer group plans (small group, large group, MercyCare Premier, MercyCare Select), and government programs (Medicare Supplement/Medigap and Medicaid/BadgerCare Plus). These plans are offered through HMO and PPO network structures. The company complements its insurance products with digital health platforms including MyChart (Epic-powered patient portal for scheduling, results, and video visits), a mail order pharmacy program, and telehealth/video visit services. MercyCare's network spans Northern Illinois and Southern Wisconsin, integrated with Mercyhealth's seven hospitals and 85+ care facilities through a vertically integrated health system.

Differentiator

Problem solved

Functional benefit

Brands

• MercyCare Premier: Large group health plans specifically designed for employers in Illinois.
• Mercyhealth partners

Products and services

• MercyCare Select Large group health plan brand offering 2-tier, 3-tier, and 4-tier formulary options for employer groups.
• Marketplace Individual & Family Plans Qualified Health Plans offered through HealthCare.gov and getcovered.illinois.gov, organized into Bronze, Silver, and Gold metal tiers based on cost-sharing structures, for individuals and families in Northern Illinois and Southern Wisconsin.
• Direct Individual & Family Plans Health insurance plans purchased directly from MercyCare outside the Marketplace, for individuals and families in Wisconsin and Illinois.
• Employer & Group Plans Group health insurance plans for businesses including small group, large group, and workplace wellness programs with HRA integration options.
• MercyCare Premier Large group health insurance plans specifically designed for employers in Illinois.
• Medicare Select (Medigap) Medicare Supplement insurance offering additional coverage for Medicare beneficiaries to fill gaps in Original Medicare.
• Senior Supplement (Medigap) Medicare Supplement insurance providing additional coverage options for Wisconsin seniors.
• Mercyhealth Partners PPO PPO health plan featuring tiered provider network benefits with access to MercyCare network providers and First Health complementary network for members.
• Medicaid / BadgerCare Plus Wisconsin Medicaid managed care plan covering ForwardHealth and BadgerCare programs for eligible low-income individuals and families in Wisconsin.
• Mail Order Pharmacy Program Home delivery prescription service offering free medication delivery for maintenance medications to MercyCare members in Wisconsin and Illinois.
• Telehealth / Video Visits Mercyhealth teleMedicine service enabling secure video visits with primary and specialty care physicians via the MyChart platform.
• Wellness Programs Population health management, smoking cessation, behavioral health, health risk assessments, and health and wellness programs offered to MercyCare members.

Quantifiable outcome

• MercyCare placed in top 5% of health plans nationwide for member experience (2024 HX Pinnacle of Excellence Award)
• +2 more outcomes

Named customers5 records

Segments4 records

Ideal customer profiles4 records

Technology focussed No

API detail

Has API

Yes

API docs

API detail

Core technology

AI maturity

App detail

Integration7 records

Feature3 records

Partnerships

Six partnerships are on record, tiered core and minor.

• HealthCare.govcoreChannel Partner/ Reseller/ DistributorFederal Health Insurance Marketplace where MercyCare lists qualified health plans. Customers can compare and enroll in MercyCare plans through this platform.
• getcovered.illinois.govcoreChannel Partner/ Reseller/ DistributorIllinois state-based Health Insurance Marketplace. MercyCare offers Illinois marketplace plans through this platform for state residents.
• First Health NetworkcoreTechnology or IntegrationFirst Health complementary network provides additional Tier 1/Tier 2 provider access for MercyCare PPO plans. Integrated into Mercyhealth Partners PPO network tiers.
• Centers for Medicare & Medicaid Services (CMS)coreOthersFederal regulatory agency requiring interoperability compliance. MercyCare implements FHIR APIs and patient access rules per CMS requirements.
• HealthSherpaminorChannel Partner/ Reseller/ DistributorInsurance enrollment platform partner. MercyCare agents can enroll customers through HealthSherpa marketplace integration.
• Navitus Health SolutionscoreTechnology or IntegrationPharmacy benefit manager providing prescription drug portal, formulary management, and drug pricing information for MercyCare members.

Scale indicators6 records

Recent moves6 records

Expansion highlights6 records

Direct peers

• Quartz Health Plan: Wisconsin-based regional health plan owned by a multi-system integrated provider network (UW Health, Gundersen, UnityPoint). Closely mirrors MercyCare's regional integrated payer-provider model, employer group focus, and Wisconsin service area.
• Dean Health Plan: Wisconsin regional health plan affiliated with SSM Health, offering HMO, POS, and Medicare Advantage plans to employer groups and individuals. Same vertically integrated, regional-issuer profile as MercyCare.
• Network Health: Wisconsin-based health plan affiliated with Froedtert/ThedaCare integrated systems, serving individuals, families, and employers across the state. Same payvider structure and Wisconsin regional footprint.
• Group Health Cooperative of South Central Wisconsin (GHC-SCW): Wisconsin regional cooperative health plan offering HMO and POS products to employer groups and individuals in southern Wisconsin. Comparable regional scale, integrated provider relationships, and employer-led GTM.
• Security Health Plan: Wisconsin-based regional health plan affiliated with Marshfield Clinic Health System. Offers HMO, PPO, Medicare Advantage, and Medicaid plans in Wisconsin — closely comparable product mix and integrated-system origin.
• Aspirus Health Plan: Wisconsin and Upper Michigan regional health plan owned by Aspirus Health System, offering individual, family, employer, and Medicare plans. Same regional integrated-system payer model.

Regional players

• Blue Cross Blue Shield of Illinois: State Blues licensee in Illinois, operating a much larger regional footprint that overlaps with MercyCare's Northern Illinois service area across Marketplace, employer, and Medicare lines.

Broad incumbents

• Anthem Blue Cross Blue Shield Wisconsin: Wisconsin Blues plan and broader Anthem platform offering commercial, Marketplace, and Medicare products across MercyCare's core southern Wisconsin geography at significantly larger scale.
• UnitedHealthcare: Largest national health insurer competing head-on in Wisconsin and Illinois employer group, Marketplace, and Medicare Supplement segments. Represents the primary large-scale incumbent competitor.
• Humana: National insurer with strong Medicare Advantage and Medigap focus, competing in MercyCare's southern Wisconsin senior segment. Relevant given MercyCare's Medigap and senior supplement offerings.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat5 records

Key risks6 records

Key highlights7 records

Customer concentration

• Xx.com/mercycarehealth
• YouTubeyoutube.com/mercyhealth
• Facebookfacebook.com/mercyhealthsystem
• LinkedInlinkedin.com/company/mercycare-insurance-company-inc-
• Instagraminstagram.com/mercyhealth_wi_il

Compliance7 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles4 records

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about MercyCare Health Plans