link to page 1 
May 11, 2020
Overview of Assisted Living Facilities
Assisted living is a generic term often applied to
with disabilities who generally require a lower level of care
community-based residential settings that provide housing
than is provided in institutional settings. ALFs typically do
and meals (i.e., room and board), as well as a range of long-
not provide the level of skilled nursing and rehabilitation
term services and supports (LTSS), to older adults and
services or continuous care offered in nursing homes.
individuals with disabilities. LTSS can include personal
Accommodations such as private rooms, private baths, and
care, medication assistance, and housekeeping, as well as
kitchenettes vary by setting.
social and other health-related activities. States license
these residential settings and refer to them by a variety of
In 2016, ALFs provided capacity for 996,100 licensed beds.
names (e.g., board and care homes, adult foster care,
Settings ranged in size from 4 to 518 licensed beds, and the
personal care homes, group homes, and supported living
average bed capacity was 35 licensed beds. About 8 in 10
arrangements, among others). This In Focus uses the term
ALF providers are for-profit entities, and the majority of
assisted living facilities (ALFs) to refer collectively to
providers (57%) are chain-affiliated (i.e., owned by an
community-based residential settings.
organization that has two or more communities). Almost
half of ALFs surveyed were authorized or certified to
In 2016, an estimated 28,900 ALFs and similar residential
participate in the state-federal Medicaid program, which is
communities provided housing and supportive services to
a means-tested entitlement that finances primary and acute
811,500 residents, according to the most recent National
medical care, as well as LTSS.
Study of Long-Term Care Providers conducted by the
Centers for Disease Control and Prevention (CDC). CDC’s
Resident Demographics
survey of licensed residential care communities is based on
The overwhelming majority of residents in ALFs were aged
data obtained from state licensing agencies in each of the 50
65 and over (93.4%), with more than half aged 85 and over
states and the District of Columbia. To be eligible for this
(52.1%). Most residents were female (70.6%) and non-
national study, a setting must be licensed, registered, listed,
Hispanic white (81.4%). About 4 in 10 residents were
certified, or otherwise regulated by the state to
diagnosed with Alzheimer’s disease or related dementia.
However, 14.3% of ALFs indicated they offered a dementia
provide room and board with at least two meals a day
care unit within the facility, and another 8.7% served only
and around-the-clock, on-site supervision;
residents with dementia. ALF residents were most likely to
help with personal care, such as bathing and dressing,
report needing assistance with bathing and walking. Fewer
and health-related services, such as medication
residents reported the need for assistance in transferring
management;
from bed or eating (see Figure 1).
have four or more licensed, certified, or registered beds;
have at least one resident currently living in the
Figure 1. Percentage of LTSS Users Needing
community; and
Assistance with Activities of Daily Living
serve a predominantly adult population.
(ALFs and similar residential care communities)
The estimated number of ALFs from this study is likely an
undercount, as it does not include settings licensed to
exclusively serve individuals with severe mental illness,
intellectual disability, or developmental disability, and it
does not include smaller settings with fewer than four beds.
ALFs are considered community-based settings, as opposed
to institutional settings such as nursing homes. In
comparison, 15,436 nursing homes with 1.6 million total
beds participated in Medicare and/or Medicaid as of April
2020. This In Focus provides information on ALF setting
characteristics and resident demographics, using data from
the 2016 National Study of Long-Term Care Providers. It
also discusses ALF costs and financing, as well as
regulation and oversight.
Source: L. Harris-Kojetin, M. Sengupta, et al., Long-Term Care
Residential Setting Characteristics
Providers and Services Users in the United States, 2015–2016, National
Assisted living is considered part of a continuum of long-
Center for Health Statistics, Vital Health Stat 3(43) 2019.
term care services. It is a concept that grew out of a desire
Notes: ALF = Assisted Living Facility; LTSS = Long-Term Services
to offer housing and services options to seniors and adults
and Supports.
https://crsreports.congress.gov
Overview of Assisted Living Facilities
Costs and Financing
personal care and other Medicaid-covered LTSS must meet
The cost of ALF care varies depending on the level of
state-based Medicaid provider requirements. Alternatively,
services a resident needs. In addition, ALF costs can vary
ALFs may contract with Medicare or Medicaid providers to
based on setting size, geographic location, and range of
offer covered home health, personal care, and other covered
services provided, among other factors. The 2019 Genworth
LTSS in their settings to participating residents.
Cost of Care Survey found the median annual ALF cost was
about $48,600, whereas the median annual cost of nursing
States that choose to cover certain Medicaid-covered LTSS
home care was more than $90,100 for a semiprivate room
provided in ALFs may provide the services under their
and $102,200 for a private room. These estimates are
Medicaid state plan or under a federal waiver program.
national figures and can vary widely by geographic region.
States most frequently provide assisted living services
For example, at the state level, the median daily rate for a
under Section 1915(c) of the Social Security Act, which
one-bedroom, single occupancy unit in an ALF ranged from
provides Home- and Community-Based Services (HCBS)
$95 to $371.
waiver authority subject to approval by the federal Centers
for Medicare & Medicaid Services (CMS). CMS requires
Assisted living is predominantly a private pay industry.
state waiver agreements to include specific statutory and
Residents and their families generally are responsible for
regulatory requirements and assurances, including that the
paying privately out-of-pocket for room and board, as well
state will safeguard Medicaid participants’ health and
as for services provided in these settings; some residents
welfare. States must identify, subject to CMS agreement,
may use private long-term care insurance to cover these
the type of information they will collect and provide to
costs. The federal Medicare program for the elderly and
CMS to review as evidence in meeting these requirements.
certain disabled individuals does not cover LTSS provided
in ALFs. Medicaid can cover ALF services as Medicaid-
On January 16, 2014, CMS issued a final rule for Medicaid
covered LTSS for eligible participants; however, Medicaid
participants receiving HCBS, effective March 17, 2014.
does not cover room and board. Essentially, the federal
The rule established certain requirements for home- and
Medicaid statute delineates that housing is separate from
community-based settings, including requirements for
health and social services provided to an individual in a
provider-owned or controlled settings such as ALFs. To
private home or residential setting. CDC’s Survey of
receive federal reimbursement, states must ensure that
National Long-Term Care Providers found that 16.5% of
Medicaid HCBS are delivered in settings that meet certain
residents in ALFs had Medicaid as a payer source for some
qualities, such as being integrated in the community,
health and social services in 2016. To assist low-income
offering residents choice among settings, ensuring
residents with the cost of room and board, some states and
residents’ rights and personal independence, and offering
local governments may have state or local-only funded
choice of services or providers. Provider-owned or
programs, with eligibility based on financial need.
controlled settings also must meet the following conditions:
tenancy agreements, residents’ privacy within their units,
Regulation and Oversight
residents’ ability to control their own schedules and visitor
In general, ALFs and similar residential settings are not
access, and physical accessibility. The final rule requires
regulated by the federal government. Instead, they are
states to develop a process, approved by CMS, to transition
licensed and regulated by states. Because ALFs do not
their current programs into compliance with the home- and
receive dedicated federal financing for services similar to
community-based setting requirements within a five-year
nursing homes, the federal government has not set
period. CMS extended the transition period for compliance
minimum ALF quality or staffing standards that would be
until March 17, 2022.
parallel to Medicare and Medicaid Requirements of
Participation (RoP) for skilled nursing facilities (SNFs) and
Long-Term Care Ombudsman Program
nursing facilities (NFs). (The federal government also has a
The Long-Term Care Ombudsman Program (LTCOP) is a
regulatory framework for oversight, inspection,
consumer-advocacy program that aims to improve the
investigation, and enforcement of RoP standards that are
quality of care and the quality of life for residents in
not applicable to ALFs).
nursing homes, ALFs, and similar residential communities
by responding to the needs of those facing problems in such
Some large ALFs may include Medicare-covered SNF care
facilities. There are 53 LTCOPs operating in all 50 states,
or Medicaid NF care. For example, ALFs could offer such
the District of Columbia, Guam, and Puerto Rico, and 523
care as part of a continuum of services in Continuing Care
local programs as of 2018. LTC ombudsmen complement
Retirement Communities. Institutional care provided in
state officials who enforce facility-focused quality
such multipurpose settings must meet Medicare and/or
standards required under state statute or regulation. Among
Medicaid RoPs to receive program payments.
their many functions, ombudsmen provide services to
protect residents’ health, safety, welfare, and rights; to
In addition, ALFs may provide Medicare- and Medicaid-
resolve residents’ complaints about the quality of their care;
covered services such as home health or personal care to
and to provide information, education, and consultation to
their residents, similar to the way these services otherwise
residents, families, and staff regarding resident interests.
would be provided in a private residence. ALF providers
that seek Medicare or Medicaid reimbursement for home
Kirsten J. Colello, Specialist in Health and Aging Policy
health services must meet federal home health agency
IF11544
requirements. ALFs that seek Medicaid reimbursement for
https://crsreports.congress.gov
Overview of Assisted Living Facilities
Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to
congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress.
Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has
been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the
United States Government, are not subject to copyright protection in the United States. Any CRS Report may be
reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include
copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you
wish to copy or otherwise use copyrighted material.
https://crsreports.congress.gov | IF11544 · VERSION 1 · NEW