Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Adult Congregate Care Facilities/Assisted Living Facilities

12/01/2003

Adult Congregate Living Facilities (ACLFs) have operated in Florida since 1975. In 1992, the state had 1500 facilities (most of which had 16 or fewer beds) serving approximately 50,000 people a year, most of them private pay. These facilities provided room and board, assistance with one ADL plus personal services, and supervision of self-administered medication.14

In 1993, a new licensing category of ACLF was implemented, called Extended Congregate Care (ECC).15 The rationale for the creation of this new category was that the state did not have a residential care option for people who needed substantial levels of personal or home health care, but not the level of skilled nursing care provided in nursing homes. Consequently, individuals with this level of impairment had to enter a nursing home, at a much greater expense to the state. The ECC licensing category addressed this gap.

  • The ECC licensure category was designed to allow residents to age in place but was not intended to be a scaled down nursing home license. Rather, it was intended to create a residential care entity that incorporated the values of the state's in-home programs: autonomy, privacy, dignity and aging-in-place in the least restrictive environment.

  • Initially, ECC services were only available to private pay residents. Few facilities serving lower-income residents applied for the license until the Assisted Living for the Elderly (ALE) waiver program was implemented as a small pilot in 1995 and was then expanded statewide in 1997.

In 1995, adult congregate living facilities were renamed assisted living facilities (ALFs). ALFs are defined as a residential care setting that provides housing, meals, personal care services, and supportive services to one or more adults of all ages who are typically unable to live independently and are not related to the owner or administrator by blood or marriage. ALFs are for elderly or disabled persons who do not need 24-hour nursing supervision, except for those receiving hospice services from a licensed hospice, who may continue to reside in an assisted living facility.

  • Four ALF licensure types are available: standard, limited nursing service, limited mental health, and extended congregate care. Facilities applying for a specialty license must first meet the criteria for a standard license.

  • In 2002, Florida had 2307 ALFs with 77,369 beds; of these, 3,207 were ALE waiver beds. In 2002, ALFs reported 13,338 potential beds for persons eligible for OSS and ACS, though as of June 2002, not all were filled.16 During the state fiscal year 2001-2002, the Assisted Living for the Elderly waiver program served 3,982 individuals.


  1. Manard, B. et al., op.cit.

  2. The information on the creation of the ECC licensing category is drawn from a report prepared for the Commission on Long Term Care in Florida, Assisted Living and Extended Congregate Care: The Florida Experience, by Larry Polivka, Victoria M. Sims and Jennifer R. Salmon, Florida Policy Exchange Center on Aging, August, 1996, with additional comments from a number of personal interviews conducted in October 2002.

  3. Salmon, J. R., et al., Affordable Assisted Living Facilities: Government-Sponsored Benefits for Reimbursing Assisted Living Services, Room, and Board, Florida Policy Exchange Center on Aging, Tampa, Florida, September 15, 2002.

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