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Texas - Assisted Living Facility — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

Texas Health and Human Services Commission (HHSC) licenses Assisted Living Facilities (ALFs) under Texas Administrative Code Title 26, Chapter 553, and funds these services primarily through the STAR+PLUS Medicaid managed care program. The service provides a 24-hour living arrangement that combines housing, personal care, supervision, and assistance with daily activities for adults who are elderly or have disabilities.

Approval requires securing a Type A or Type B state license via the Texas Unified Licensure Information Portal (TULIP), passing life safety and health inspections, enrolling as a provider through the Texas Medicaid & Healthcare Partnership (TMHP), and successfully credentialing with regional STAR+PLUS Managed Care Organizations (MCOs). Securing an active network contract with at least one regional STAR+PLUS MCO dictates whether a licensed facility can actually bill Medicaid for services rendered.

1. Service Definition and Scope

In Texas, an Assisted Living Facility (ALF) provides congregate residential care, personal care services, and supervision. HHSC categorizes ALFs into distinct license types based on the residents' ability to evacuate the facility and their need for nighttime attendance.

Facilities may also obtain specialized certifications to market specific types of care, such as Alzheimer's services, which require adherence to additional environmental and staffing regulations.

2. Regulatory and Oversight Agencies

The Texas Health and Human Services Commission (HHSC) is the primary state agency responsible for licensing, inspecting, and regulating ALFs. Medicaid provider enrollment is managed by a separate state contractor, while daily Medicaid service authorization is handled by managed care plans.

Providers must interact with multiple state portals and regional entities to maintain both their facility license and their Medicaid billing privileges.

3. Gatekeeping Prerequisites: Who Can Even Apply

Texas does not utilize a Certificate of Need (CON) program or impose state-level moratoria on new Assisted Living Facility licenses. Any entity that meets the physical plant, zoning, and background check requirements may apply for a license through HHSC.

However, access to Medicaid reimbursement is strictly gated by managed care network needs. A facility can be fully licensed by the state but unable to serve Medicaid participants if regional health plans are not accepting new providers.

4. Licensure and Certification Requirements

All ALFs must be licensed by HHSC under Texas Administrative Code, Title 26, Chapter 553 before admitting residents. The process requires submitting an application through TULIP and passing rigorous physical plant and operational inspections.

Licenses are issued for a specific capacity and type, and they cannot be transferred to new owners or locations without formal HHSC approval.

5. Medicaid Provider Enrollment

After obtaining an ALF license from HHSC, facilities wishing to serve Medicaid clients must enroll as providers through the Texas Medicaid & Healthcare Partnership (TMHP). This establishes the facility's foundational Medicaid record.

Once enrolled with TMHP, the facility must separately apply for credentialing and contracting with the STAR+PLUS MCOs operating in their specific service region.

6. Staffing, Training and Background Checks

Texas does not mandate strict numerical staff-to-resident ratios for ALFs, instead requiring facilities to maintain sufficient staff to meet the specific needs of all residents at all times. Recent regulatory updates have modernized the required background check systems.

Training requirements vary based on the facility's license type and whether they provide specialized care, such as dementia support.

7. Documentation, Policies and Records

ALFs must maintain comprehensive operational records, resident files, and emergency plans subject to HHSC review at any time. Recent legislation has significantly expanded emergency preparedness requirements.

Facilities must also provide clear, written disclosures to residents regarding their rights, facility rules, and the scope of services provided.

8. Billing, Rates and Claims

Medicaid reimbursement for ALF services in Texas is managed through the STAR+PLUS waiver program. Claims are submitted to the resident's specific MCO rather than directly to the state.

It is critical to note that Medicaid waiver funds cover the cost of care and services, but federal rules prohibit Medicaid from paying for room and board in these settings.

9. Approval Sequence and Timeline

Becoming a Medicaid-enrolled ALF in Texas is a multi-stage process that begins with local physical plant approvals and ends with managed care contracting. The entire sequence can take several months to over a year depending on construction and inspection schedules.

Providers cannot bill Medicaid until the final MCO contract is executed, even if the facility is fully licensed and operational.

10. Common Denials and Survey Findings

HHSC conducts unannounced surveys and investigates complaints. Facilities are frequently cited for physical plant deficiencies and administrative gaps in personnel records.

Failure to maintain compliance can result in administrative penalties, license revocation, or termination of Medicaid MCO contracts.

11. Key Contacts and Resources

Providers must utilize official state portals for licensing and enrollment, and refer to the Texas Administrative Code for current regulatory standards.

Staying subscribed to HHSC provider communications is required by contract and essential for tracking regulatory updates.

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