Assisted living facilities are a type of residential facility where older adults and people with disabilities may live when they are unable to live safely or comfortably in their own home. In assisted living facilities, residents typically live in their own room or apartment and share common areas. They have access to services including meals, supervision and security, social activities, and home care (also known as “home and community-based services” or HCBS). About one million people live in assisted living facilities in the U.S, though that number varies slightly between sources because of differing definitions of assisted living. Other types of residential care facilities include board and care homes, nursing facilities, and continuing care retirement communities. The costs of assisted living facilities (which averaged $64,200 in 2023) tend to be lower than those of nursing homes but higher than those of living independently, and most people pay for the costs of assisted living by themselves. Medicare does not cover the costs of assisted living, but Medicaid may cover the home care services residents receive and offer other protections for residents with Medicaid. It is unknown how many assisted living facilities accept Medicaid, but the National Center for Assisted Living estimates that Medicaid pays for daily services for about 200,000 people (approximately one in five residents).
There are expectations of major changes to Medicaid through Congressional or executive actions that could have implications for people in assisted living facilities who rely on Medicaid coverage. Although Medicaid law prohibits states from covering assisted living room and board expenses, states’ home care programs may offer some coverage. Using data from the 22nd KFF survey of officials administering Medicaid home care programs in all 50 states and the District of Columbia (a state for the purposes of this analysis), which states completed between April and October 2024, this issue brief describes the circumstances under which Medicaid covers services provided in assisted living facilities, and protections the Medicaid program offers to residents of assisted living facilities. Key findings include:
- Most state Medicaid programs (41) cover home care services provided to eligible residents in assisted living facilities under some circumstances (Figure 1, Appendix Table 1).
- 34 states cover personal care provided in assisted living facilities and 29 states make services such as personal care available to residents 24 hours a day, 7 days per week.
- Half of states (25) offer protections against eviction beyond what is required under federal law, but only 10 states require assisted living facilities to accept new residents who are covered by Medicaid.
What home care services are covered by Medicaid in assisted living facilities?
While federal Medicaid statute requires states to cover the costs of nursing facilities, including both room and board and the costs of care, nearly all home care is optional for states to cover. Many older adults and people with disabilities move into assisted living facilities when they require assistance with the activities of daily living (such as eating and dressing) and the instrumental activities of daily living (such as preparing meals and managing medication), as an alternative to nursing facilities. Although Medicaid does not cover room and board in assisted living facilities, Medicaid may cover home care for assisted living facility residents and some states may have policies in place to defray the costs of room and board (see below).
41 of the 47 responding states cover services provided in assisted living facilities through at least one Medicaid home care program (Figure 1, Appendix Table 1). Medicaid home care can be offered through either the Medicaid state plan or as part of a specialized waiver. Benefits offered through a state plan are generally available to all Medicaid enrollees who need them, whereas waivers allow states to offer services that are targeted to a specific population. States may also use waivers to provide a broader set of services and to limit the number of people who can participate in the waiver. States most commonly provide home care in assisted living facilities through 1915(c) waivers (32 states), which are generally tailored to specific populations. States less commonly offer home care through 1115 waivers (6 states), the personal care state plan benefit (8 states), or the Community First Choice option (3 states).
People who are ages 65 and older or have physical disabilities are the most likely to be eligible for Medicaid coverage of home care in assisted living facilities. Among the 32 states that cover home care in assisted living facilities for a specific population, 30 states do so using waivers that target adults who are ages 65 and older or have physical disabilities. Only 24 states provide home care in assisted living facilities to support other targeted populations including: waivers for people with intellectual or developmental disabilities (9 states), traumatic brain injuries (5 states), mental health conditions (3 states), HIV/AIDS (1 state), and medically fragile/technology dependent children (1 state).
Thirty-four states cover personal care provided in assisted living facilities and twenty-nine states make services such as personal care available to residents 24 hours a day, 7 days per week (Figure 2, Appendix Table 2). KFF asked states about what services they provide in assisted living facilities through Medicaid home care programs using the Centers for Medicare and Medicaid Services’ (CMS) list of services, which are categorized in a comprehensive taxonomy. The taxonomy was developed to provide common language for describing home- and community-based services across waivers and state plans. CMS defines personal care services—the most commonly covered benefit—as services provided to help Medicaid enrollees remain in their homes and communities rather than live in institutional settings, such as nursing homes. Such services generally include assistance with the activities of daily living such as eating and bathing or the instrumental activities of daily living such as managing medication. In Medicaid, round-the-clock services (provided by 29 states) are a defined benefit in which a provider takes responsibility for the health and welfare of a person 24 hours a day, 7 days a week. Other services covered by many states in assisted living facilities include case management (24 states); nursing (22 states); equipment, technology, and modifications (21 states); and non-medical transportation (19 states, Figure 2, Appendix Table 2).
What protections does the Medicaid program offer to residents of assisted living facilities?
Although states are prohibited from using Medicaid funds to pay for the costs of room and board, Paying for Senior Care reports that 47 states (including D.C.) provide some level of assistance to Medicaid enrollees in assisted living. (Paying for Senior Care is an online source of information about financial resources for seniors, and is owned and operated by Caring, LLC, which maintains directories of and offers referrals to senior care providers.) Medicaid enrollees have relatively low incomes and fewer savings compared to other adults, which could make it difficult to afford the full price for a room at an assisted living facility. Paying for Senior care reports that common forms of assistance from Medicaid include capping the costs assisted living facilities may charge Medicaid enrollees and using Medicaid funding to pay for meal preparation and service. Such supports are permissible because in the first case, Medicaid is not spending any money, and in the second case, Medicaid is not paying for food, but rather for help preparing and eating it, which is considered a form of personal care. Beyond Medicaid, there are 44 states that provide additional supplemental security income (SSI) to cover assisted living costs, and SSI recipients are generally eligible for Medicaid.
Although those programs help residents afford the costs of assisted living, they may also discourage assisted living facilities from caring for Medicaid enrollees, particularly because Medicaid payment rates tend to be lower than what people would pay out-of-pocket. In 2023, Wisconsin made national news on account of seniors being evicted from assisted living facilities after they had spent all of their savings on home care and became eligible for Medicaid.
Federal law provides some protections against eviction for assisted living residents who become eligible for Medicaid. Assisted living facilities that accept Medicaid are considered to be a home and community-based setting, as defined under the HCBS Settings Rule. Under the provisions in this rule, assisted living facilities providing home care under Medicaid must provide “comparable protections” as to what tenants have under landlord-tenant law in a given state, county, and city. Since these protections are driven by local landlord-tenant law, eviction protections vary by where a facility is located. The protections at an absolute minimum generally mean that a resident cannot be evicted without written notice and a trial, and are more extensive in some localities.
In addition to federally required protections, 25 of 47 responding states have additional eviction protections in place for Medicaid enrollees who live in assisted living facilities and are unable to pay the monthly fees (Figure 3, Appendix Table 3). The most common protection (15 states of 25) requires facilities to transition people into a new facility if they are unable to pay monthly fees. Some states noted using care coordination agencies or case managers to coordinate moving residents to a new facility if they were facing an eviction. A small number of states (9 of 25) prohibit assisted living facilities from evicting residents if they are paying the state-determined payment amount for room and board. Such states have limits on the monthly fees assisted living facilities can charge Medicaid enrollees that are calculated based on enrollees’ income. An additional 2 states have similar protections in place for people who are using home care provided through managed care plans and Kansas prohibits assisted living facilities from evicting people under any circumstances.
New Jersey and Oklahoma require all assisted living facilities to accept Medicaid enrollees as new residents and eight other states require assisted living facilities to accept Medicaid enrollees if they receive Medicaid payments (Figure 4, Appendix Table 4). It is not known what percentage of assisted living facilities receive Medicaid funding or how many states require them to do so, and most states do not require assisted living facilities to accept new residents who are enrolled in Medicaid.
This work was supported in part by Arnold Ventures. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.
