Other Residential Care Facilities (U.S.) — NAICS 623990

A Histometrics industry primer for public-market and private investors

1. Overview

The North American Industry Classification System (NAICS) code 623990 — "Other Residential Care Facilities" — is the catch-all bucket for round-the-clock residential care that doesn't fit the industry's other, more specialized boxes. In plain terms, it covers places where people live and receive supervision and personal care but not skilled nursing or a hospital-level medical program: youth group homes, group foster homes, orphanages and children's homes, homes for unwed mothers, halfway houses for delinquents and ex-offenders, non-correctional "boot"/disciplinary camps for at-risk youth, and group homes for disabled people who need help but not nursing [1].

Why it matters to an investor: this is a small, deeply fragmented, and overwhelmingly government-funded corner of the U.S. care economy. Roughly $9.2 billion in annual receipts flows through the private employer businesses the federal government can measure [2] — but the money is almost entirely public: Medicaid, federal foster-care dollars, and state and county child-welfare and juvenile-justice contracts. That makes demand durable (someone always has to house these populations) while revenue stays rate-capped, politically exposed, and lately under intense scrutiny for abuse and neglect.

The two ways in are very different. Public-market investors have no clean way to play this industry — there is no pure-play listed company; the nearest listed exposure sits inside prison operators (residential reentry / halfway houses) and behavioral-health hospital chains, where 623990-type activity is a small slice of a much larger business. Private investors dominate the field: nonprofits and government run most of it, and for-profit operators — increasingly private-equity-backed roll-ups — own the rest. The economics, the risks, and the headlines all run through those private hands.

Judgment: the opportunity is attractive only where an operator combines durable local referrals, reliable reimbursement, disciplined staffing, and superior compliance. The most common mistake is treating a diversified public healthcare company's revenue as if it were exposure to this narrow industry.

2. What it is and how it's structured

Scope. Code 623990 sits under the residential-care family (NAICS 623). It captures establishments that combine a place to live with supervision, personal care, or both — but which fall outside the four specialized residential-care industries. The Census Bureau's illustrative examples are telling: non-correctional boot/disciplinary camps for delinquent youth; group homes for the hearing- or visually-impaired; child group foster homes; halfway group homes for delinquents or ex-offenders; homes for unwed mothers; group homes for disabled persons without nursing care; and orphanages [1].

What it explicitly excludes (and where those activities live instead):

• Residential intellectual- and developmental-disability (IDD) facilities → 623210 [1]
• Residential mental-health and substance-abuse facilities → 623220 [1]
• Continuing-care retirement communities (CCRCs) → 623311; assisted-living for the elderly → 623312 [1]
• Skilled nursing / rehabilitative nursing facilities → 623110 [1]
• Temporary emergency and homeless shelters → 624221 (community housing services) [1]
• Privately operated correctional facilities → 561210 (facilities support services) [1]
• Government-operated juvenile correctional institutions and camps → 922140 [1]
• Agencies that arrange foster placements without operating the home → child and youth services (624110) [1]

That boundary matters. The "troubled teen" and youth-treatment ecosystem people read about in the news is spread across several of these codes at once (psychiatric hospitals, substance-abuse residential, IDD facilities, and 623990). Numbers quoted for that whole ecosystem are not numbers for 623990 alone. The practical dividing line is the service delivered at each site, not the operator's brand — a single company often owns facilities across several NAICS categories, which makes company-level exposure hard to isolate.

Ownership mix. Three types of operator share the field:

1. Government — county- and state-run juvenile group homes, publicly operated children's homes and detention alternatives.
2. Nonprofits — the traditional backbone (Boys Town, Devereux, faith-based children's homes, and hundreds of regional charities) [15][16].
3. For-profits — from single-home mom-and-pop operators up to private-equity-backed multi-state chains such as Sevita, Embark Behavioral Health, and Family Help & Wellness [18][24][25].

The federal figures below capture only the private (nonprofit + for-profit) employer businesses. They do not capture government-operated facilities, and they cannot capture care delivered by individual paid foster families, who are not "establishments" at all. The federal data also provides no national ownership split, so no precise public-versus-private percentage should be inferred. Treat the official receipts as the measurable private slice, not the true size of the social function.

3. How big it is

Federal statistics for NAICS 623990 (our ground-truth figures):

A few things stand out. Payroll (~$5.2 billion, 2023) is large relative to receipts (~$9.2 billion, 2022) — even allowing that the two series come from different years and that payroll is not revenue, this is clearly a labor business, not a capital-intensive one. The average establishment has about 20 employees (118,478 ÷ 5,988), confirming that most sites are small group homes rather than large institutions. And with 3,601 firms sharing ~$9 billion, the average firm books only about $2.5 million in receipts — comfortably under the U.S. Small Business Administration's (SBA) $16 million small-business threshold [4].

The undercount caveat is important here. County Business Patterns covers only establishments with paid employees; it excludes the self-employed, businesses without employees, and most government employment [5]. The Economic Census generally excludes government-owned establishments even when their activity mirrors a covered private industry [6]. So government-run juvenile group homes and public children's homes are outside these totals, and paid individual foster homes are outside the scope entirely. The societal spend on housing these populations is therefore materially larger than $9.2 billion. For scale, advocacy and reporting estimates for the broader youth residential / "troubled teen" ecosystem — which spans several NAICS codes — put annual public funding around $23 billion and cite well over 10,000 programs nationwide; that figure is not comparable to the 623990 line but shows how much sits just outside it [8].

One more caution: do not stitch these numbers into a single margin calculation. Receipts and concentration are 2022 Economic Census; payroll and employment are 2023 County Business Patterns; payroll is not revenue [2][3].

4. The investable universe

There is no pure-play public company whose reported revenue maps cleanly to NAICS 623990. Listed exposure is indirect and small; the real operators are mostly private nonprofits, government, or private-equity holdings.

Listed companies with 623990-type activity (all partial exposure):

For GEO and CoreCivic, the 623990-relevant piece (halfway houses) is a minor segment of businesses built around secure detention. GEO exited direct youth-services operations in 2021, transferring management contracts to a newly independent nonprofit (Abraxas) while keeping the underlying real estate [9]. Acadia and UHS are behavioral-health operators whose youth residential beds sit largely in adjacent codes — useful for context and disclosure practice, not a clean 623990 proxy [12][13][14].

Major private and nonprofit operators (representative, not exhaustive):

5. How the money works

Owners here make money the way a hotel with a captive, publicly-funded clientele does: revenue = licensed beds × occupancy (census) × per-diem rate, minus a labor-heavy cost base.

The payers. Almost all revenue is public: Medicaid (including waivers, and the EPSDT benefit — Early and Periodic Screening, Diagnostic and Treatment — for children), Title IV-E of the Social Security Act (the federal foster-care funding stream), and direct state/county child-welfare and juvenile-justice contracts. Payment can be per resident-day, per month, per authorized service, or under a negotiated contract. A smaller "private-pay" tier exists in the troubled-teen segment, where families pay out of pocket [8][12][18].

The per-diem gap is the whole game. Payers reimburse a daily rate per child or resident, and rates vary enormously by level of care. A child in an ordinary foster home generates a maintenance payment on the order of ~$30 a day; the same child placed in a residential treatment center can generate roughly $275 to more than $800 a day, billed to Medicaid and Title IV-E [8]. One large for-profit, Sequel, was reported to collect up to ~$800 per day per child, with about 90% of revenue coming from public programs [17]. That gradient is what makes higher-acuity congregate care financially attractive to operators — and is exactly what critics call a perverse incentive to institutionalize kids.

Cost structure and margins. The major costs are direct-care labor, supervision, housing, food, transportation, training, insurance, compliance, maintenance, and rent. Residential care is labor-intensive because staffing must be available even when a home isn't full [7]. Because payroll is more than half of receipts [2][3], profitability lives and dies on two levers: labor cost (direct-care wages, overtime, turnover, agency labor) and census (empty beds still carry fixed staffing and licensing cost). Reimbursement-funded segments run on thin margins — the daily rate is set administratively, so an operator can't simply raise prices to cover wage inflation. For-profit and PE operators add value chiefly through scale (spreading back-office and compliance cost), payer-mix optimization (shifting toward higher-acuity, higher-per-diem placements), and, in some cases, owning the real estate under the beds (GEO's retained youth facilities are an example) [9].

Metrics that actually matter here: average daily census / occupancy; per-diem or revenue per resident-day after denials and adjustments; direct-care labor cost per resident-day; staff vacancy, turnover, overtime, and agency-labor use; payer mix (Medicaid vs. IV-E vs. state contract vs. private pay); length of stay and authorization approvals; licensed bed capacity; and serious-incident, complaint, and licensing-deficiency counts. Same-facility census and labor productivity are more informative than retail same-store sales, and public behavioral-health operators disclose useful analogues (occupancy, length of stay, revenue per patient-day, salary expense) even when they aren't classified in 623990 [13]. Nonprofits track the same operating metrics but supplement reimbursement with donations and grants and reinvest any surplus rather than distribute it.

Judgment: a small home carries substantial fixed staffing cost, so a modest drop in occupancy, reimbursement, or staffing availability can produce an outsized fall in facility-level cash flow.

6. What drives demand

• Availability of foster families. When there aren't enough foster homes, child-welfare systems fall back on group homes and congregate care; researchers attribute much of the persistent reliance on congregate care to that shortage [27].
• The youth behavioral-health crisis. Rising rates of serious mental-health and behavioral needs among children feed demand for residential and therapeutic placements [12][25].
• The shift toward community living. Medicaid policy favors services in integrated community settings over large institutions, sustaining demand for group homes, supported living, and foster-care alternatives for both youth and disabled adults [30].
• Medicaid rate adequacy and budgets. Waivers and state-plan programs are the funding channel; rate adequacy, waiting lists, and state budgets determine how much capacity providers can profitably operate [30][31].
• Child-welfare and juvenile-justice caseloads and policy. Diversion and deinstitutionalization push volume down in some settings and up in others (fewer secure facilities can mean more community group homes).
• Policy caps on congregate care. The Family First Prevention Services Act of 2018 (FFPSA) cut off federal Title IV-E reimbursement after 14 days for group placements that aren't an accredited "Qualified Residential Treatment Program" (QRTP), a deliberate push away from congregate care [28][29].

Notably, the policy squeeze has not emptied the beds. The number of foster youth in congregate settings nationally has held around 40,000 since FFPSA took effect, even as the overall foster population fell [29]. Among 13–17-year-olds specifically, congregate placements edged down from ~27,500 (2023) to ~26,100 (2024) — a continuation of a long, slow decline rather than a collapse [27]. The demand base, in other words, is sticky.

Judgment: underlying need is relatively defensive, but need does not automatically translate into attractive returns — funding, referral rules, staffing, and quality performance decide which operators benefit.

7. Regulation

This is a heavily regulated, license-gated business, and the regulatory temperature is rising. There is no single national license: requirements vary by state, population served, facility type, payer, and contract, and typically include facility licensing, fire and building standards, background checks, staff qualifications, medication controls, incident reporting, abuse-prevention rules, and audits.

• State licensing is the license to exist. Each state licenses child-caring institutions, group homes, and foster facilities and can suspend or revoke a license — which, for an operator, means immediate loss of the revenue and often impairment of the underlying asset.
• Federal funding rules shape the economics. Title IV-E and the FFPSA/QRTP accreditation regime govern what congregate care the federal government will co-fund [28][29], while Medicaid's EPSDT benefit and Home- and Community-Based Services (HCBS) rules govern medical-model reimbursement. For HCBS, the Centers for Medicare & Medicaid Services (CMS) requires person-centered planning and settings that support privacy, autonomy, and community access [30]. CMS's 2024 Medicaid Access Final Rule added requirements on incident management, grievances, waiting-list reporting, payment transparency, direct-care compensation, and quality reporting [30], with states set to report on the standardized HCBS quality-measure set beginning in 2028 [31]; the rule directs a larger share of Medicaid dollars to direct-care wages [33]. Psychiatric residential treatment facilities (PRTFs) and intermediate-care facilities for people with intellectual disabilities carry additional federal certification and safety requirements, though they sit in adjacent NAICS codes [32].
• Medicaid eligibility is tightening. The 2025 federal reconciliation law tightened Medicaid financing, and CMS rules now phase in community-engagement ("work") requirements — generally 80 hours per month of work, education, or community service for certain adults ages 19–64 — no later than 2027, subject to exceptions [34][39]. Many children and residents served by this industry fall outside the rule, but it can shift payer mix and eligibility in adult programs.
• Oversight and enforcement scrutiny is intense. In June 2024 the U.S. Senate Finance Committee released a two-year investigation, "Warehouses of Neglect," documenting systemic abuse, improper restraint and seclusion, and unsafe conditions at major youth residential operators, and framing the harm as inherent to a profit-maximizing, taxpayer-funded model [35][36]. In October 2024 the committee's chair asked the Department of Justice (DOJ) to investigate potential Medicaid fraud and civil-rights violations [37]. States have acted too — California banned sending foster youth to out-of-state facilities after regulators investigated a PE-owned provider [8].

The direction of travel — tighter accreditation, restraint/seclusion limits, funding restrictions on congregate care, and reputational enforcement — raises compliance cost and headline risk for every operator, and disproportionately threatens the for-profit model.

8. Competitive dynamics and consolidation

The industry is extraordinarily fragmented. Federal concentration data show the largest four firms hold just 6.3% of revenue, the top eight 9%, the top 20 15.3%, and even the top 50 only 25.8% [2]. (The Herfindahl-Hirschman Index, or HHI — the standard concentration measure — is suppressed in the federal data for this code, so no value is stated here [2].) With 3,601 firms and no dominant player, this is a textbook fragmented, roll-up-ready industry.

Competition is fundamentally local: providers compete for licenses, referral relationships, qualified staff, county and state contracts, payer credentials, and community acceptance. National scale can improve recruiting, billing, compliance, training, purchasing, and data systems, but local licensing and staffing constraints cap the benefits of centralization.

On the for-profit side, private-equity firms have been buying and combining youth-services and behavioral-care providers — owners named in reporting include Centerbridge Partners and The Vistria Group (Sevita/National Mentor), Consonance Capital (Embark), and others — betting on scale economics and per-diem arbitrage in a business with steady public funding [8][18][24][38]. Consolidation can invite scrutiny even where national concentration looks low: in 2026 the Federal Trade Commission (FTC) required Sevita to divest 128 intermediate-care facilities and related assets in Indiana, Louisiana, and Texas after reviewing its acquisition of BrightSpring's ResCare Community Living [19][20]. Those facilities were adjacent to 623990, but the action shows local-market concentration and quality concerns can trigger antitrust remedies. Meanwhile the traditional backbone — nonprofits like Boys Town and Devereux, plus government agencies — is not going anywhere [15][16].

The result is a barbell: a stable nonprofit/government core, a churn of small local operators, and an aggressive for-profit consolidation layer that is drawing most of the capital and most of the criticism.

Judgment: the best consolidation strategies are likely to be compliance-led and operationally disciplined. Roll-ups that lean mainly on occupancy increases, aggressive staffing cuts, or opaque ownership structures carry disproportionate downside risk.

9. Risks

• Reimbursement risk (the big one). Revenue is set administratively by Medicaid and Title IV-E; rate freezes, FFPSA-style funding restrictions on congregate care, or broader Medicaid cuts (the 2025 reconciliation law tightened Medicaid financing) hit the top line directly, and rates may not keep pace with wages, rent, insurance, and food costs [28][29][39].
• Eligibility risk. Medicaid eligibility or waiver changes — including the new community-engagement requirements — can reduce funded resident volume or alter payer mix [30][34].
• Labor risk. A chronic direct-care worker shortage is the binding operational constraint: surveys report roughly 95% of providers facing moderate-to-severe staffing shortfalls, with many turning away referrals — and worker pay is effectively capped by Medicaid rates [40].
• Quality, safety, and litigation risk. Abuse, neglect, restraints, elopements, medication errors, or poor outcomes can trigger litigation, license loss, contract termination, and reputational damage; a license loss can also impair or strand the underlying real estate [8][25][32][35][37].
• Occupancy / policy-shift risk. Deliberate policy moves away from congregate care can strand beds, and fixed staffing and licensing costs make low census expensive.
• Referral / payer concentration. Losing one county contract, school district, hospital relationship, or managed-care payer can materially hurt a small operator, and heavy dependence on a few government payers means limited pricing power and exposure to budget cycles.
• Leverage risk. Private-equity ownership, sale-leasebacks, and layered management companies can raise fixed obligations and cut operating flexibility.
• Data risk. Public statistics and company filings often blend exact-code operations with adjacent services, making market-share and valuation comparisons unreliable [2][12].
• ESG and headline risk. This is one of the most reputationally charged corners of the care economy; the "profiting from vulnerable children" narrative screens the sector out of many funds and invites activist and media attention [8][35].

10. How to invest, and the outlook

Public markets (limited and indirect)

There is no pure-play listed company; use public names as exposure to selected subsegments, not as 623990 investments. The nearest listed exposure is the residential-reentry (halfway-house) segments of GEO Group (GEO) and CoreCivic (CXW) — small pieces of secure-detention businesses, both heavily ESG-screened [9][10][11]. Behavioral-health operators Acadia Healthcare (ACHC) and Universal Health Services (UHS) run youth residential beds, but those sit largely in adjacent NAICS codes inside hospital-centric portfolios [12][13]. For BrightSpring (BTSG), adjust for the ResCare Community Living divestiture; treat Brookdale (BKD) as an assisted-living comparison, not a peer [19][26]. When analyzing any of them, examine behavioral-health census, occupancy, revenue per patient-day, payer mix, staffing costs, legal reserves, and debt. Value the relevant segment using enterprise value to EBITDA (earnings before interest, taxes, depreciation, and amortization), free-cash-flow yield, leverage, and return on invested capital — and only weigh dividend yield or share price after confirming the earnings actually come from the targeted residential-care exposure.

Private markets (where the industry actually is)

Direct ownership or operation of licensed group homes is feasible but demanding — success turns on securing state licenses and Medicaid/child-welfare contracts, managing a scarce direct-care workforce, and surviving intense oversight. Practical routes include:

• Acquiring a licensed local operator, or building a multi-site platform via add-on acquisitions (the most active institutional route, but carrying the sector's sharpest reputational and regulatory risk) [8][18].
• Private credit secured by contracted cash flows.
• Owning the real estate leased to a licensed operator — a lower-headline, though still concentration-exposed, way to participate (the model GEO retained after exiting operations) [9].
• Technology or services supporting staffing, compliance, scheduling, and remote monitoring.

Diligence should start with facility-level licensure, payer contracts, reimbursement history, occupancy, staff turnover, incident records, claims, working capital, and maintenance needs — separating real-estate value from operating value and stress-testing reimbursement, occupancy, staffing, and regulatory scenarios independently. Nonprofit participation (Boys Town, Devereux, faith-based homes) runs on reimbursement plus philanthropy and does not offer investor returns.

Outlook

The demand base looks structurally durable: the youth behavioral-health crisis and a persistent shortage of foster families keep congregate placements sticky even against policy trying to shrink them [27][29]. But revenue is capped by Medicaid and Title IV-E rates, while the cost base is squeezed by a direct-care labor shortage that only higher public rates can fix [39][40]. Layer on escalating oversight — the Senate "Warehouses of Neglect" report, a DOJ referral, state placement bans, and FTC antitrust action — and the for-profit model faces rising compliance cost and real regulatory risk even as capital keeps flowing into roll-ups [20][35][37]. The most likely path is continued for-profit consolidation, a stable nonprofit/government backbone, and margins that stay thin and politically contingent. Returns will be highly operator-specific: the strongest businesses pair durable referral channels, high-quality care, stable staffing, and scalable compliance; the weakest assume uninterrupted occupancy and funding. Near-term watch items: Medicaid financing under the 2025 reconciliation law and the 2027 community-engagement rules, FFPSA/QRTP implementation, CMS HCBS wage and quality rules, and the next wave of state licensing enforcement [30][33][34][39].

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Sources

1. U.S. Census Bureau, 2022 NAICS Definition — 623990 Other Residential Care Facilities (definition, illustrative examples, cross-references), 2022. https://www.census.gov/naics/?chart=2022&details=623990&input=623990
2. U.S. Census Bureau, 2022 Economic Census — receipts, firm counts, and concentration ratios (CR4/CR8/CR20/CR50; HHI suppressed), NAICS 623990, 2022. https://api.census.gov/data/2022/ecnsize.html
3. U.S. Census Bureau, County Business Patterns: 2023 — establishments, employment, annual and first-quarter payroll, NAICS 623990, 2023. https://www.census.gov/data/datasets/2023/econ/cbp/2023-cbp.html
4. U.S. Small Business Administration, Table of Size Standards, 2023. https://www.sba.gov/document/support-table-size-standards
5. U.S. Census Bureau, County Business Patterns Methodology (coverage; excludes nonemployers and most government), 2026. https://www.census.gov/programs-surveys/cbp/technical-documentation/methodology.html
6. U.S. Census Bureau, Understanding NAICS (Economic Census exclusion of government-owned establishments), 2022. https://www.census.gov/programs-surveys/economic-census/year/2022/guidance/understanding-naics.html
7. U.S. Bureau of Labor Statistics, Nursing and Residential Care Facilities: NAICS 623, 2026. https://www.bls.gov/iag/tgs/iag623.htm
8. Private Equity Stakeholder Project, The Kids Are Not Alright: How Private Equity Profits Off of Behavioral Health Services for Vulnerable and At-Risk Youth, 2022. https://pestakeholder.org/reports/the-kids-are-not-alright-how-private-equity-profits-off-of-behavioral-health-services-for-vulnerable-and-at-risk-youth/
9. Wikipedia, GEO Group (GEO Care / youth-services divestiture to Abraxas), 2025. https://en.wikipedia.org/wiki/GEO_Group
10. StockTitan, The GEO Group Reports Fourth Quarter and Full Year 2024 Results (total revenue ~$2.42 billion), 2025. https://www.stocktitan.net/news/GEO/the-geo-group-reports-fourth-quarter-and-full-year-2024-081hcfnk5ggk.html
11. CoreCivic, Inc., Form 10-K / 2024 Annual Report — CoreCivic Community segment (reentry centers, beds, occupancy, revenue), 2024. https://www.sec.gov/Archives/edgar/data/1070985/000114036125011095/ny20038715x3_ars.pdf
12. Acadia Healthcare Company, Form 10-K for Fiscal Year 2025 (277 behavioral-health facilities, 12,500+ beds), 2026. https://www.sec.gov/Archives/edgar/data/1520697/000119312526078266/achc-20251231.htm
13. Universal Health Services, Form 10-K for Fiscal Year 2025, 2026. https://www.sec.gov/Archives/edgar/data/352915/000119312526071676/uhs-20251231.htm
14. NBC News, Residential treatment centers put profits ahead of children's safety, Senate report finds (Acadia, UHS context), 2024. https://www.nbcnews.com/news/us-news/residential-treatment-centers-senate-report-rcna155177
15. Boys Town, About Boys Town and Residential Care, 2025. https://www.boystown.org/about
16. Wikipedia, Devereux Foundation (total revenue ~$494 million, 2024), 2025. https://en.wikipedia.org/wiki/Devereux_Foundation
17. Unsilenced, The Troubled Teen Industry — What Is TTI? (Sequel revenue, per-diem rates, public-funding share), 2025. https://www.unsilenced.org/the-industry/
18. Stateline, Private equity snaps up disability services, challenging state regulators (Sevita/National Mentor ownership and scale), 2025. https://stateline.org/2025/05/16/private-equity-snaps-up-disability-services-challenging-state-regulators/
19. BrightSpring Health Services, BrightSpring Completes Sale of ResCare Community Living to Sevita, 2026. https://ir.brightspringhealth.com/news-releases/news-release-details/brightspring-health-services-completes-sale-rescare-community
20. Federal Trade Commission, FTC Finalizes Consent Order in Sevita–BrightSpring Acquisition (128 intermediate-care facilities divested in IN/LA/TX), 2026. https://www.ftc.gov/news-events/news/press-releases
21. Dungarvin, About Us, 2026. https://www.dungarvin.com/about-us/
22. RHA Health Services, About RHA, 2026. https://rhahealthservices.org/about-rha/
23. Benchmark Human Services, About, 2026. https://benchmarkhs.com/about/
24. Behavioral Health Business, Consonance Capital Partners Acquires Majority Stake in Youth-Focused Embark Behavioral Health, 2023. https://bhbusiness.com/2023/02/09/consonance-capital-partners-acquires-majority-stake-in-youth-focused-embark-behavioral-health/
25. Associated Press, Adopted and Locked Away: Kids Promised "Forever Homes" Instead Confined in For-Profit Institutions (Family Help & Wellness), 2026. https://apnews.com/
26. Brookdale Senior Living, Form 10-K for Fiscal Year 2025 (senior/assisted-living comparator; NAICS 623312), 2026. https://www.sec.gov/Archives/edgar/data/1332349/000133234926000032/bkd-20251231.htm
27. Child Trends, The Number of Older Youth in Congregate Foster Care Decreased in 2024, 2025. https://www.childtrends.org/publications/older-youth-congregate-foster-care-decreased-2024
28. Congressional Research Service, Family First Prevention Services Act, Insight IN10858. https://www.congress.gov/crs-product/IN10858
29. Child Welfare Monitor, Surprise, surprise! Family First has not reduced the use of congregate care! (congregate population held ~40,000; QRTP 14-day rule), 2026. https://childwelfaremonitor.org/2026/03/24/surprise-surprise-family-first-has-not-reduced-the-use-of-congregate-care/
30. Centers for Medicare & Medicaid Services, Home and Community-Based Services Provisions / 2024 Medicaid Access Final Rule, 2024. https://www.medicaid.gov/medicaid/access-care/home-and-community-based-services-provisions
31. Centers for Medicare & Medicaid Services, Home and Community-Based Services Quality Measure Set (reporting beginning 2028), 2026. https://www.medicaid.gov/medicaid/quality-of-care/quality-improvement/measuring-and-improving-quality-home-and-community-based-services
32. Centers for Medicare & Medicaid Services, Psychiatric Residential Treatment Facility Providers, 2025. https://www.cms.gov/medicare/health-safety-standards/certification-compliance/psychiatric-residential-treatment-facility-providers
33. Disability Scoop, Feds Finalize New Rules For Medicaid Home And Community-Based Services (direct-care wage share), 2024. https://www.disabilityscoop.com/2024/04/25/feds-finalize-new-rules-for-medicaid-home-and-community-based-services/30849/
34. Centers for Medicare & Medicaid Services, Medicaid Community Engagement Requirement for Certain Individuals (80-hour/month rule phasing in by 2027), 2026. https://www.cms.gov/newsroom/fact-sheets
35. U.S. Senate Committee on Finance, Wyden Investigation Exposes Systemic Taxpayer-Funded Child Abuse and Neglect in Youth Residential Treatment Facilities ("Warehouses of Neglect"), June 12, 2024. https://www.finance.senate.gov/chairmans-news/wyden-investigation-exposes-systemic-taxpayer-funded-child-abuse-and-neglect-in-youth-residential-treatment-facilities
36. OPB, Senate report says US taxpayers help fund residential treatment facilities that put vulnerable kids at risk, 2024. https://www.opb.org/article/2024/06/12/senate-report-us-taxpayers-fund-residential-treatment-facilities-that-put-vulnerable-kids-at-risk/
37. U.S. Senate Committee on Finance, Wyden Asks DOJ to Investigate Medicaid Fraud by Youth Residential Treatment Facilities and Potential Civil Rights Violations by States, October 9, 2024. https://www.finance.senate.gov/chairmans-news/wyden-asks-doj-to-investigate-medicaid-fraud-by-youth-residential-treatment-facilities-and-potential-civil-rights-violations-by-states
38. The American Prospect, Rollups: Private Equity Eyes Youth Treatment Centers as a Takeover Target, 2024. https://prospect.org/power/rollups-private-equity-eyes-youth-treatment-centers-as-takeover-target/
39. KFF, Payment Rates for Medicaid Home Care Ahead of the 2025 Reconciliation Law, 2025. https://www.kff.org/medicaid/payment-rates-for-medicaid-home-care-ahead-of-the-2025-reconciliation-law/
40. Home Health Care News, For Patients With Intellectual And Developmental Disabilities, Access To HCBS Remains Grim (direct-care worker shortage; provider staffing survey), 2024. https://homehealthcarenews.com/2024/03/for-patients-with-intellectual-and-developmental-disabilities-access-to-hcbs-remains-grim/