She Drove a Camper Across the US to Crack the Medicaid Code with Tzivya Murrin

Welcome back to the Good Steward Law and Wealth Podcast. I'm excited to be here today because we're going to talk Medicaid. And I have the owner of Sensible Senior Planning, and I call her T. I'll let you pronounce your name. I don't want to mess it up, but T is here.

Yes. Hi, Ledly Jennings. Thanks for having me on. My first— my full name is Sylvia, but like you said, I just go by T. It's a little complex.

Yeah, I was gonna give it a shot, but then I figured I might as well let you get it right the first time. Ledly Jennings is a kind of a unique name too. So I don't ever meet anyone with that. But anyway, we— so my firm, we do what we call elder law, but essentially it is a version of estate planning, but we're helping clients prepare for their long-term care. And then through that comes with applying for Medicaid a lot of times. And then in a roundabout way, I met Tee and then started using her company to do a lot of my Medicaid applications because she is great at it. And it is just something that if you don't know what you're doing or have the bandwidth to do it, then it can get pretty complicated. And a lot of clients don't really see that. So I wanted to have Tee on here to kind of go over what Medicaid planning is, how that application process works. And yeah, but I guess to start, I guess, Tee, how did you get into this? Where did— how did you get into the Medicaid planning space?

So my background is I started working really, um, in healthcare, working at a pediatric nursing home, and then about like 13 years ago shifted to working with geriatrics, and I was a social service coordinator in a geriatric nursing home. There I was helping families with the Medicaid process. Then I went on to get my administrator's license, and I was an administrator at an assisted living facility. And there I— we did not accept Medicaid, but we would have residents that were running out of funds and they would need to start the Medicaid application process so that they can have a smooth transition from the assisted living to a facility that accepted Medicaid. So I was heavily involved with the Medicaid process from there. But from a facility standpoint, and really what our role was within the facility, it was not anything in regards to protecting assets for the clients or even educating them because we weren't uneducated on that in regards to asset preservation or ways to expedite the Medicaid application process. So I, you know, just always loving to advocate for those that are, you know, maybe less fortunate or don't have the resources. I kind of went on a quest to learn more about Medicaid planning and understand how asset preservation works for crisis Medicaid planning, and then the Medicaid application process, the ins and the outs. So I did work for a short, uh, brief period of time for another Medicaid planning company that specializes in application, and they themselves too, they only did applications. They did not do any asset preservation. And that's, you know, I continued on, so it's like, you know, I'm gonna, I'm gonna dive into really asset preservation, understanding that so that we can properly help advocate for, for the seniors. Um, so went on, got about 5 and a half years ago, got a camper, and this was right when COVID started, but literally went all over the US in a camper, met with Medicaid offices, elder law attorneys, and my focus was really the Medicaid offices, but to learn a lot, a lot about Medicaid, the ins, the outs, applications, state-specific rules, different tricks and hints, and then met with attorneys to learn crisis planning, and then started Sensible Senior Planning. A little over 5 years ago. So, and that's, that's all I do day in, day out is just everything as it relates to crisis Medicaid planning and the Medicaid application process.

Wow, I didn't know that story about the camper. That's, that's a cool story. You really dove in the weeds there.

I did. I did.

That's what we said. Half the stuff we do, Linda in my office always says, you know, the only way we learn is actually getting in and doing it. And then we— so I guess that's the best way to learn is actually get out out there. Yeah. And I know, which I'll kind of hit briefly just for everyone listening, what, why you need Medicaid planning. And just from our perspective, what we do is asset protection mostly and is pre-planning. So I do a lot of trust. Most of our planning is revocable trust, but I've talked about another podcast when we do long-term care planning, and that's when we plan ahead and bring in irrevocable trust and various things. But essentially, if you go to the nursing home, you have to pay for. And if how you pay for it is where the planning comes in, there's all kinds of options. You can private pay, meaning you pay for it out of pocket, but the fees, I guess in Arkansas, probably $8,000 to $9,000 a month. So a lot of people can't or don't want to do that. So maybe they have long-term care insurance or, or they can get on Medicaid. And that is where we come in with the Medicaid planning. And how we help clients. So if they don't pre-plan, meaning we've helped them, you know, 5 or 10 years ahead of time plan and get things moved around, then they have to apply for Medicaid in what we call crisis planning. So I guess, Tee, generally, how do you view Medicaid planning at a broad level? And how do you describe it?

Yeah, I think the way I would describe Medicaid planning, crisis Medicaid planning, is where we try and preserve as much assets as we can in a Medicaid-compliant way. Having, you know, Medicaid is aware of the entire plan, it's all Medicaid-compliant, but preserving as much assets as we can. I, I usually say that when a couple is, is married, we typically can preserve 100% of their assets. Sometimes it may mean that a property has to get sold, or, and we just can preserve the value of the property, but typically you can save about 100% of the assets. And when someone is single, then usually you can save at least 50% of the assets. Of course, every circumstance can be different, but it typically comes out between— I say 50%, that's usually on the lower end. A lot of times it's higher than that. But really, the Medicaid planning is being able to preserve as much as we can in a Medicaid-compliant way.

Yeah, yeah. And I agree, that's typically what I tell clients. If you're married, we have a lot more tools in our belt essentially to save, you know, almost everything. But even if you're single, then there's still some planning and a lot of value we can do there rather than losing it all, basically. And one thing that comes up on my end that I really didn't know till I dove into this space, what does Medicaid cover that Medicare does not? How, what's the difference in those two?

Yeah, so don't like say I'm not necessarily an expert when it comes to the Medicare side. And though I will say just from my experience from having worked in a facility, so I always say everyone always, you wanna check with the providers, but typically Medicare covers the skilled nursing. So it's gonna cover therapy in a facility. It will also cover sometimes inpatient rehab. The inpatient rehab that it covers, typically it's up to 21 days, I believe it is still without a copay. And after 21 days there is a copay. So depending on if you have a secondary insurance, The secondary insurance may pick that up, or at that point you may be private pay or may need Medicaid. Um, but Medicare— the, the, the clients that, that we work with for crisis planning, really the biggest difference is that Medicare does not pay for 24/7 care for someone to live in a facility for long term. Um, their thing is, you know, what they pay for is for someone to— who needs inpatient rehab, they'll pay for the inpatient rehab, and with doing that, they're going to pay for the room and board. But they don't care if someone you know, needs care. That's not what they're looking for. It's really the inpatient rehab. Medicare— and this is one of the biggest things that I speak with people, and they're like, and I'm sure, Ledly Jennings, you hear this too— they're like, hey, yeah, my loved one just went into the facility February 20th, and they have 100 days of Medicare, so we're gonna need Medicaid in 3 or 4 months because they still have 100 days of Medicare left, or at this point maybe they only have 85 days left. And I always say to them, you know, the way it works is with Medicare, typically the facility does reviews depending on the situation, anywhere from 3 to 5 days. Usually they speak to Medicare and they'll give Medicare a review, or they'll send in notes to Medicare and give a review on the, um, on the progress of the loved one who's in the facility. If the loved one is making too much progress where they don't need inpatient rehab because they're making too much progress, or they're making too little progress where inpatient rehab isn't helping them enough, um, or, you know, they've just plateaued, then Medicare just gives— it's usually, I believe now it's a 72-hour notice, or it might be 48, 48 hours or 72-hour notice where they say you're done with Medicare, you gotta go home. And so even though it's— you hear the 100 days, it's a max of 100 days. It's very, very rare that anyone gets, gets 100 days. The average that we're seeing is people are getting about 3 weeks at most of coverage in a facility. So it's, you know, that's the portion that people sometimes don't realize when it comes to Medicare. They think they're good for a few months, but really you're not. You kind of want to get on, on the long-term plan right away because you may only get a 48-hour notice.

Yeah. And that's, that's why we always say you think you have a long runway, but you need to start the planning and start gathering everything for the actual Medicaid application as soon as possible. Possible because if you get that 72-hour notice, that's a lot to do in a short amount of time. And then just briefly on Medicaid, how do you qualify? Like, what are the base qualifications as far as asset level and timing and process?

Yeah, so the first thing, the qualification is definitely there's always the clinical eligibility. So the individual has to meet clinical eligibility where they require 2 activities of daily living. Very rare do we have seniors that won't fall into the category. From a financial standpoint, their assets— for a single person who's applying, their assets can only be a max of $2,000. So it can't exceed $2,000. Their income can't exceed— it's about, I think it's a little over $2,900 now— um, that their income can't exceed. However, for a single person, again, that's where it is where we do that crisis planning. If their income is above $2,900. And remember, that is the gross amount. So it's not if, let's say, that hits their bank account is only $2,800, but their gross amount before taxes withholding or Medicare is above that, then we need to set up a qualified income trust, or also known as a Miller trust. And that's, um, you know, Ledly, I know you help with the— Ledly will prepare— you'll prepare the legal documents for that. And then, um, it's just setting— taking the legal documents and setting up a bank account where the the income that puts the individual above the limit funnels through the Miller Trust. So there's ways again about that if someone doesn't qualify from income. And from asset standpoint, there's— and I don't know if how much you want me to get into it, but there's a half a loaf strategy where we can gift some funds, put some funds into a Medicaid product called Medicaid-compliant annuity, um, that will pay for a penalty period because we gifted some funds. So, and basically there's definitely options. And in case, usually, like we said, we'll save at least 50% of the assets. Sometimes it can be less when it comes to mathematical equations, sometimes more.

But yeah, yeah. And that's usually where we start. Like, well, I guess if they're married or single, we always do planning. Like, the quick and easy stuff is spending on allowable things. You know, they're allowed to have a house. So if the house needs some repairs or something like that, we can spend on that. Long or funeral plans. We always talk about that. And then my favorite part is attorney's fees are included in that spend down. So, they can pay attorney's fees. But yeah, and then the half a loaf strategy, that's one of our favorite tools in the tool belt. We work with annuity planners. And just from my experience on those is it's a really qualified specialty of annuities. You don't want to go to any just annuity salesman out there. They need to know about Medicaid-compliant annuities. That's just one thing I've learned out there.

Yeah, I've had that happen before where an attorney will call me and say, you know, they got an annuity set up and then we review the annuity and it's not Medicaid compliant. It has to be Medicaid compliant. And most financial advisors don't assist with that because it's not— it's typically not commission-producing. So, and if it is commission-producing, it would be very, very minimal. So usually financial advisors don't typically touch that. And yeah, and I think I spoke about the single, but the married portion, that we, as we know, is a little bit different if someone's married when it comes to Medicaid. So when someone's married, typically the, in the, um, we'll call for the, the sake of the conversation, institutionalized spouse, that's the individual who needs care, they, their assets can also only be $2,000 and it's the same income limit. Limit. However, the spouses, they have— they don't have an income limit. So the spouse's income essentially is not counted, um, but they do have an asset limit. And the— to determine that asset limit, there is some— there's a date that's called a snapshot date. And basically, based off of that date and what an individual's assets are on that date is how much we can determine what the healthy spouse can keep. And that's where it is where if the healthy spouse, let's say they have a total of $300,000 and the healthy spouse can only keep for, you know, purpose of this, $140,000, um, then what we are able to take that other $160,000 and preserve that 100% for the healthy spouse. So, you know, again, that's where it is. We're from a From that standpoint, instead of just taking that $160,000 and spending that down and paying the nursing home, we can take that and, and preserve that so that the institutionalized spouse can get on Medicaid right away.

Yep, exactly. Yeah, and that just goes into the value of the planning. Like, it's just you got to know the snapshot dates, you got to know all the qualifications and the timing of things. That took me a while when I first started getting into this, is knowing that everything had to happen at a certain time. Now, so I just know this because originally we were doing all the applications ourselves, and between me running a law firm and Linda in my office doing everything else, we got overwhelmed quick. So I know how tedious and tough the actual application process is. Could you kind of describe how that process goes? And then more importantly, how you stay on top of everything because you're very organized and—

I guess you'd call it task-oriented about how to get things done in a sequence. Yeah, so Arkansas is like its own beast. I mean, it is just so different than most other states when it comes to the Medicaid application. Um, so, and of course it depends according to the caseworkers and things like that, but essentially the actual filling out of the Medicaid application is fairly straightforward. Not that difficult, but you always want to make sure that, you know, you're filling it out correctly so you don't put too much information, too little information. Where it comes to a lot of the tedious work is that if, let's say, I were to just go ahead and, okay, you know, my mom's assets are below $2,000 and her income is okay, I can just fill out an application because it's very straightforward. I will go fill out an application, the caseworker will review it, and then come back to me. And they typically only give 10 calendar days, not business days, 10 calendar days to get the documents to them. Sometimes they'll give you an extension if you call and ask for one. So at most you might get 20 days, but you have to be on top of that. And they come back to you and they'll give you a whole slew of a list of all the documents that will be needed. Every case is very specific as to what's needed. So if I don't get that, they, let's say, send me this list and they need, let's say, a premium letter for the health insurance company. If I don't get that, that letter, then Medicaid will deny. However, let's say I, I apply in March. Medicaid doesn't get back to me until middle of April, and they're giving me 10 days. I call them after the 10 days and I say, hey, I didn't get the letter yet and I need an extension. They give me another 10 days. Now it's May. I get the letter I give it to them. They don't— they, they are right. They have so many cases, it can take them months to review it. They don't review that letter until May or June. Come June, they review that letter, and let's say they say, nope, it doesn't have a date on, on the letter. They'll say, there's no date on the letter, we're denying your case. They deny the case. You just now, all these months that you were planning on getting Medicaid paid for Medicaid is not going to get paid for because you didn't have a date on the health insurance letter. You have everything else but not that. So what's very tedious and where a lot of the work comes in, what's so important is making sure that you're knowledgeable, whoever is applying for Medicaid, or, you know, for us, that we're actually knowledgeable with exactly what Medicaid is going to need so that when Medicaid comes back and asks us for things, we have it right away to give it to them. Or we know we can get it, but that we feel confident when we're giving them the documents, it's actually what they need. There's instances I've had where the caseworker, I'll call the caseworker and they'll be like, well, I was just getting ready to deny the case because I saw you fax in 2 documents, but they're not clear. And the caseworkers aren't going to pick up the phone. They don't have enough time. They just can't with the workload. You might find some that will, but my experience 90% won't pick up the phone and say, hey, these two documents came through unclear, um, we're gonna deny the case. What they do instead is they just deny the case. So from the standpoint of, like, you know, from our work, what we do is, of course, the first step is that we want to ensure that we have every document that Medicaid's going to need. Then of course we complete the spend down, so that— which is usually the asset preservation. We then need proof and documentation that the client is actually eligible because we need to prove that to Medicaid, and only then do we apply. By the time we apply, usually at that point the family has very minimal involvement, if any, because we already have everything that we anticipated Medicaid to ask for. Then when we, we submit the application, and Arkansas specifically will usually fax in the application So we fax in the application. We always call about 2 to 3 days after because— and families don't even realize this because we don't— there's no, there's no need. We got it all under control. But I can't tell you how many times you call 2 or 3 days after to confirm that they received it and they say that they only received half of the fax or they didn't get the fax at all or the fax went into the wrong person's chart and they thought it was for someone else. So we always have to call to follow up to make sure they actually got it. And then we follow up usually a couple weeks because it usually takes— right now it's taking about 3 weeks for a caseworker to be assigned. So we'll follow up a couple weeks later to find out who is the caseworker. We'll then get their contact information. At times they won't give you the caseworker's contact information, so they'll say, well, leave a voicemail, leave a voicemail for the caseworker, we'll transfer you to her, and if she wants to give you her direct number or email, she can give it to you. So they'll transfer you, you'll leave a voicemail for the caseworker, she doesn't call you back, you gotta call again the day later and the day later. So there's a lot of follow-up that has to get done, um, and then, you know, it can take the caseworker a few weeks to actually review it and then let you know if anything else is needed. So there's just— there's so much staying on top and repetitive phone calls and making sure things are moving forward, um, so that you can catch any issues before it turns into an issue. Or any obstacles before it turns into an issue. So that's really, you know, our involvement. Of course, once we get— there are times I'll say, and this is, you know, where you may get a denial, but in Arkansas, if you get a denial, you do have 60 days for them to reopen the case. So, and let's say in this case where they say, okay, the paperwork wasn't clear, If you give it, show them the clear copy, then within 60 days, then, um, they'll reopen the case. However, it can take the caseworker over 60 days to get to review that paper to make sure it's clear, and then they won't open it because it's past the 60 days. So you need to again keep following up, follow up with the supervisors, follow up with whatever you need to do, and keep following up until we can get the case back open. So it's just, it's a lot of time, a lot of follow-through that's needed, and you want to make sure whoever's persisting is really following through.

Yeah, and yeah, you don't see that from the client-facing side. You know, it's all this work that you're doing on the back end is just— it was necessary, but it is pretty cumbersome. I don't think a lot of people realize that. That's why it's always, if you have any assets and you're applying for Medicaid, you definitely need to hire somebody, a professional who knows the system. You know, we may know the law, but I've come to realize I don't know the system like Tee does. So it's the teamwork that makes it really effective. And that made me think, and then I'll— that's really good information, I guess. What would— is there any advice that you would give families that they could do now to plan ahead for this? I know obviously on the legal side we can plan ahead, but just as far as any Medicaid advice or application, what can they start staying on top of?

Yeah, I think the number one thing is getting power of attorney on file with every institution that their loved one, um, is affiliated with. So that means getting power of attorney on file with health insurance companies, with life insurance companies, financial institutions. They don't have to get their name on the accounts, they just want to get power of attorney uploaded there so that when the time does come, if they do need to get documents documents, they're not having to wait for— get power of attorney on with these companies. Because, I mean, some companies, it can take them 6 weeks to review power of attorney, accept it, and then send the documents. So I think that's the number one thing that I always tell people. And the second thing I always say is to— second thing is online, to try and get online access as soon as their loved one is allowing them to get that. To try and get online access. And then the third thing I would say is just to make sure, you know, within the past 5 years, Medicaid looks at gifting. So you just want to make sure that, you know, everything's accounted for. I would say, you know, maybe transactions $500 or more. Just want to make sure there's things that are accounted for in case if Medicaid does come back and question that.

Yeah, that's good. I'm a huge power of attorney advocate. We do, obviously, pretty well every client that comes comes to my door is going to get a power of attorney. And mine is honestly, it's about 20-something pages long. And I used to be kind of turned off by how big it was. But lately title companies and just whoever has told me they like it and are thankful for it because it authorizes us to do what we need to do, especially when I've come to see elder law and Medicaid planning. Like if you want to make a gift to a certain person, it has to be authorized in that power of attorney to actually And a lot of people don't realize that. But, and then I'll kind of wrap it up here, but I just, is there one particular like client story that comes to mind for you where you were really able to help somebody or I don't, it doesn't have to necessarily be your biggest, you know, financial win, but just a win for you and your company that comes to mind?

Yeah, I think first, just quickly on the power of attorney, I will say that I, because I work with so many different clients, so many different attorneys, It's very, very often that clients say they can't get documents because power of attorney isn't accepted. And I do a lot of work with you, and I'm not saying this to toot your horn, but I haven't had it at all. And I mean, a lot of your clients have very complex accounts, or some not, but big accounts. And there hasn't been yet where a client has come forward and said, well, I can't get this document because power of attorney isn't accepted. I need a new power of attorney. So I can say that, yes, it's very helpful. It prevents families from having to go back and forth and be frustrated that the power of attorney isn't accepted. So that is great. Now I understand why, because of the lengthiness. But from a successful story, I feel like, to be honest, I feel like every day is another successful story. So I can give a latest one of— this was just this week, but we are, you know, we The client was, uh, the facility applied for the client and the application got denied for failure to provide documentation. And we— I got all of the documents from the client that was submitted to, to Medicaid, reviewed all of the, the documents, and I'm like, I see everything there is matching up, verifications, everything is— was matching up. This was a couple months ago, um, we resubmitted an application and we were able to— we got, we got the approval yesterday without having the family needing to gather more documents. So the caseworker did come back a bunch of times and ask for documents saying I couldn't see this, or I couldn't find this, I couldn't find this. And you know, it's like they couldn't find um, a couple of statements, and one couldn't find a health insurance letter, they couldn't find an income statement. And, you know, I would right away send it to them. And this was an example how if we didn't have that open communication and that dialogue, this family just would have had another denial because it's the caseworker's kind of problem in this situation where they're just not seeing what we're submitting. But again, it's that follow-through. And, um, this one we just got the approval yesterday, which is why it's in front of my mind. But that was an example of where I would say, you know, our assistants, the family was looking at, and this facility, it was a little over $500 a day. So they were looking at a very, very hefty bill that, you know, the daughter kept saying she was losing sleep over, losing sleep over. And basically, you know, we got the approval and she texted this morning saying she had a better night's sleep than she's had in a really long time. So, you know, again, I mean, it's just, it's like that follow-up and And just knowing that we're here really to advocate for, for you and for your loved one. That's our number one priority.

Yeah, that's, that's great. I love those stories. It's, it's very rewarding when you get an approval. Yeah, but, and I try to always, I could talk about Medicaid for days because there's so many questions that I have and just so many intricacies, but I try to keep these under 30 minutes. So I cannot sing T's praises enough. Her team has made us a lot more efficient and reliable. So I thank you for that. And thank you for being on the Good Steward Law and Wealth Podcast today.

Of course. Thank you again for having me, Ledly Jennings.

Yeah, it was great to speak with you. And until next time, guys, I don't know what we'll cover next, but it'll be something interesting, I'm sure.

Thank y'all.