On your team

Nineteen-year-old Joe Schaefer’s dilemma was one of circumstance. A full-time college student for nine months of the year at Mid-State Technical College, summer was his time to put in the hours at the auto mechanic shop. That meant when Joe reported his summer monthly income to BadgerCare, he was denied coverage because his monthly income was too high to qualify for coverage. However, his annual average monthly income should have made him eligible for coverage.

Member JoeWhat’s more, Joe’s annual income was too low to be considered for Marketplace tax credits. Joe fell in the “gap” between BadgerCare and Marketplace assistance, and should have received coverage under BadgerCare’s GAP Filling program. But he didn’t. He was able to get more costly coverage through a Marketplace plan that set him up for a significant financial burden. When his lung collapsed in July 2016, he faced an estimated $8,000 in medical bills to be paid from his annual income of $10,000.

“I knew the staff at Security Health Plan cared,” said Joe’s mom, Beth Schaefer. “Anyone that answers those phones, cares. I’d trusted them for years with my insurance, so when my son got his bills and the Marketplace continued to be unable to help us, I called to see what Security Health Plan could do,” said Beth.

“I was worried we wouldn’t get anywhere and I’d be stuck with a big bill, on top of my health issues,” said Joe. But he trusted his mom and the Security Health Plan staff for help.

What followed for Beth and Joe was a year-long process of appeals and court hearings with BadgerCare – all with the help of three dedicated Security Health Plan staff. Alex L. helped Beth and Joe prepare for their Nov. 2016 phone court hearing. When the judge ruled in BadgerCare’s favor, Alex L. helped with an appeal. Monica M. and Jeff K. helped represent Joe at the Mar. 2017 phone court hearing. “We won the second appeal with BadgerCare, but the Marketplace wouldn’t allow us to backdate the end of Joe’s policy. We were running out of time. Joe’s medical claims couldn’t be reversed after one year from the date of service. At this point, I was getting run-down, but wanted to continue after coming so far. Monica told me she would continue in this battle if I wanted to continue; she wouldn’t leave me on my own. That inspired me to fight for my son,” said Beth.

After more research, Jeff was able to find an automated termination process that allowed Joe to be removed from the Marketplace. Only then could he finally be enrolled in the GAP Filling program appropriate for his income level.

With some quick work and thanks to their pre-planning, Monica and Jeff were able to get Joe’s claims and payments reversed and submitted to BadgerCare before time ran out. That meant Joe could be appropriately reimbursed for the premiums and payments he shouldn’t have been charged.

“We were so happy to get all the money back,” said Beth. “We thought we wouldn’t due to the timing. The clinic and hospital got paid from BadgerCare and Security Health Plan recouped all their claims paid out.”

“I couldn’t have done it without my mom, and she couldn’t have done it without Security Health Plan,” said Joe.

“Good came out of this terribly stressful and frustrating situation,” explained Beth. BadgerCare is considering changing policies and procedures in reaction to the Schaefer’s case. Security Health Plan staff members are being trained on the nuance that led to the Schaefer’s trouble. “I cannot express in words the emotional distress we went through,” remembered Beth, “or the unwavering help Alex, Monica and Jeff gave us. I have never experienced such dedication, knowledge and care by any company’s employees like yours. These individuals went well beyond anything I could have hoped for after we were faced with hurdle after hurdle. Please recognize these individuals for their outstanding service,” wrote Beth in a letter to the Director of Security Health Plan Member Experience and Contact Center Services, Ken Baur.

“This amount of follow-through on Mr. Schaefer’s issue is nothing short of outstanding. The issue took over 50 combined on-site visits and follow-up calls, not counting the court hearings,” said Baur. “Customer Service representatives are generally rewarded for resolving an issue in the first call, but in this case, Alex, Monica and Jeff knew the best course of action was to do whatever it took with endless determination, doing the right thing for the right reason. This is really what separates us from our competition,” Baur said.

After working with Alex, Monica and Jeff, Joe was able to return to life as normal. “I like hands-on work, which is why I’m studying welding,” Joe explained. “But I don’t need my hands that deep in my insurance.” Known as Mr. Fix-it by his friends and family, Joe can again put his efforts toward dreams like restoring his ‘68 Chevy. “And that feels good,” Joe concluded.