For buyers, sellers & owners
Tiers, Levels, and Classifications: A Field Guide to How Washington State AFHs Get Paid
Spend an afternoon with adult family home owners and you will hear about Tier 3 residents, C High, Level 4 care, and the ECS contract, sometimes in one sentence. These are not one system. They are four.
A three-part series
"Tier," "level," and "classification" get used interchangeably in AFH conversations. They are different systems, and each affects a home's income differently.
- The Field Guide · you are here
Four separate systems, who sets each one, and which survive a sale. - A Through E
The Medicaid base rate: seventeen classifications and what they pay. - CBHS Tiers
Six tiers of supportive supervision, paid on top of the base rate.
Four systems, run by different people
Each one is set by someone different, attaches to something different, and behaves differently when a home changes hands. If you are buying, selling, or operating an AFH, mixing them up leads to bad revenue assumptions. Here is the map.
| System | Who sets it | Attached to | Labels you'll hear |
|---|---|---|---|
| CARE classifications | DSHS | Each Medicaid resident | A Low … E High |
| CBHS tiers | Health Care Authority | Residents with qualifying behavioral needs | Tier 1 … Tier 6 |
| Specialty contracts | DSHS | The owner / the home | ECS, SBS |
| Private-pay care levels | The home itself | Each private-pay resident | Often Level 1 … 5 |
1. CARE classifications (A Low through E High)
This is the foundation of Medicaid payment. A DSHS assessment places each Medicaid resident into one of seventeen classifications, and each classification carries a daily rate that also depends on the county. Every Medicaid resident has one. It is lettered, never numbered. Full guide: A Through E.
2. CBHS tiers (Tier 1 through Tier 6)
This is where the word "tier" properly belongs. Community Behavioral Health Support is a Health Care Authority benefit that pays for supportive supervision of residents with qualifying behavioral needs, on top of the base rate. Tiers are defined by hours of dedicated staff time per day. Only some residents qualify. Full guide: CBHS Tiers Explained.
3. Specialty contracts (ECS and SBS)
These are contracts the home itself must qualify for and hold under the state's Residential Support Waiver. They pay in two different ways, and the difference matters when you read a seller's income. Expanded Community Services (ECS) is not an add-on to the rate: the home is paid the ECS daily rate ($256.87) or the resident's base rate, whichever is greater. (DSHS's manual bills ECS under a code it calls an "add-on"; the payment still does not stack on the base rate.) Specialized Behavior Support (SBS) is an add-on: $178.00 a day on top of the base rate, in exchange for six to eight additional hours a day of individualized staffing.
These contracts matter less than they used to. For care plans from assessments on or after July 1, 2025, a resident must first be found not eligible for CBHS before receiving SBS (existing SBS residents moved over at their next assessment, through June 30, 2026), which makes CBHS the primary route for behavioral support and means the two never stack. Both contracts come with a warning every buyer should memorize.
Specialty contracts do not transfer with the home. DSHS states that specialty contracts such as Expanded Community Services (ECS) and Specialized Behavior Support (SBS) are not transferable in a change of ownership. The new owner must qualify and hold a fully executed contract before providing, or being paid for, those services. Revenue from them cannot be assumed to survive closing.
DSHS contracting staff confirmed in September 2026 that they cannot add ECS or SBS to a new owner's contract without approval from DSHS's adult family home program staff. Residents' services continue after a sale, except the specialty services a new owner has not been granted. Whether a buyer can apply before closing, and on what terms, has been referred to the program managers for those contracts. This guide will be updated when they answer. Until then, treat specialty revenue as at risk in a sale.
How a home gets its Medicaid contract, bills ProviderOne, collects each resident's share, and qualifies for ECS or SBS: Getting Paid: ProviderOne Billing, Client Responsibility and Specialty Contracts.
A note on Meaningful Day: you will still see it listed alongside ECS and SBS, including on state pages. The 2025 state budget eliminated its funding, and DSHS contracting staff confirmed in September 2026 that Meaningful Day has not been available since July 1, 2025. Do not count it as income in a purchase.
4. Private-pay care levels
Many homes price private-pay residents as a base monthly rate plus a care-level charge, often labeled Level 1 through 5. No agency sets these. Each home defines its own levels and amounts in its admission agreement, so "Level 3" at one home tells you nothing about Level 3 at another.
Two systems that are not about AFHs at all
Search "Washington five-tier system" and you will find a 2026 rule assigning Tier 1 through 5 personal care hours. That rule belongs to a presumptive eligibility program for people receiving care in their own home, not in an adult family home. Washington also has a tiered quality incentive for nursing facilities. Neither one affects AFH income, and neither one classifies adult family homes.
The question to ask about any revenue line
Who sets it? Is it attached to the resident or to the owner? How often is it reviewed? Does it survive a sale?
| System | How often reviewed | In a sale |
|---|---|---|
| CARE classification | Reassessed as the resident's needs change | Follows the resident. No new assessment; the authorization is reissued under the new owner |
| CBHS tier | At least every 12 months | Follows the resident; new owner needs an HCA application and a contract with each resident's managed care plan |
| Specialty contract | Held under contract terms | Does not transfer. Buyer needs its own, approved by DSHS program staff |
| Private-pay level | Whenever the home reassesses | A business decision the next owner can change |
Keep reading
- A Through E: How CARE Classifications Set an Adult Family Home's Medicaid Income
- CBHS Tiers Explained: The Behavioral Health Add-On Behind Some AFH Income
- AFH Valuation Estimator and How to Finance an Adult Family Home
- Buying or Selling an AFH: the change-of-ownership process and what transfers
- Adult family homes for sale in Washington: properties, businesses, and leases currently on the market
This page is general educational information for people buying, selling, or operating an adult family home. It is not legal, financial, or reimbursement advice. Program rules and rates change; confirm current details with DSHS and the Washington State Health Care Authority.
Frequently Asked Questions