Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Negotiated Risk Agreements


There was consensus that consumers should have the option of assuming risk, but uncertainty about the correct process for doing so, particularly for persons with cognitive impairment.

  • Negotiated risk is not specifically identified as such; it is addressed indirectly. Providers are using negotiated risk--but mainly as a communication tool.

  • The state has begun to talk about negotiated risk but there are no regulations in place. There is a move to introduce this into pre-admission screening, which is done on the county level by a social worker or public health nurse. The emphasis in current thinking is not so much about insuring health and safety but whether the individual is willing to take the risk of remaining in the community and what the state is able to do to make the home more conducive to their staying in that setting. Negotiated risk is a piece of that but the state is not there yet.

  • This is a hot button issue in the state and we have not yet come to a consensus because I think we have not had sufficient consumer agreement. Younger consumers want negotiated risk, but another large group--families of the cognitively impaired--question whether people are capable of making the decisions about the risk. We are looking for a way to provide enough of a safety net in these settings to provide for the cognitively impaired. We want cognitively intact people to have the ability to accept risk, but we haven't found the right mechanism for the cognitively impaired.

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