For buyers, sellers & owners

CBHS Tiers Explained: The Behavioral Health Add-On Behind Some AFH Income

If an adult family home owner talks about Tier 2 or Tier 4 residents, this is almost certainly the system they mean. It is separate from the A through E classification that sets the base rate.

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
  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 · you are here
  Six tiers of supportive supervision, paid on top of the base rate.

What CBHS is

Community Behavioral Health Support, or CBHS, is a Medicaid benefit administered by the Health Care Authority (HCA) in conjunction with DSHS. It began July 1, 2024. It helps people who have a significant mental health diagnosis, and who need additional support, live in a community setting such as an adult family home. CBHS replaces the older Behavioral Health Personal Care (BHPC) wrap-around funding that managed care organizations used to pay, so owners who have been operating for years may still describe it in those terms.

What it pays for

The service is called supportive supervision: direct monitoring, redirection, diversion, and cueing to prevent at-risk behavior that could harm the resident or others, along with help building the skills to live stably in the community. It is staff time devoted to keeping a resident with serious behavioral needs stable. It does not pay for personal care or room and board, which are covered elsewhere.

Who can provide it

Services must be delivered by agency-contracted providers: licensed adult family homes, as well as ARC, EARC, assisted living, and enhanced services facilities. A home enrolls through ProviderOne so that HCA and the managed care organizations can contract with it, and it must contract with the managed care organizations to serve their enrollees.

The six tiers

Tiers are assigned on medical appropriateness and clinical acuity, and they are defined by the average hours per day of dedicated staff a resident requires. Anyone found eligible qualifies for at least Tier 1. Payment is based on the authorized tier.

Hour bands: WAC 182-561-0500 (the bands for Tiers 4 and 5 were revised effective May 24, 2025, so older handouts may differ). Rates: Article 7.13 of the 2025-27 collective bargaining agreement between the state and the Adult Family Home Council, in effect through June 30, 2027. The same table applies to Intensive Behavioral Supportive Supervision (IBSS), a managed-care alternative route to the same service; a resident has one or the other, never both.

Why two similar homes can have very different CBHS income

The tier belongs to the resident, not the house. A home with three Tier 2 residents and a home with none can be identical in size, location, and licensing. This is why owners say tier income "varies from home to home." What varies is who lives there. The rate does not: the collective bargaining agreement says managed care organizations shall pay these per diems, and that even one-off single case agreements will strictly adhere to the same tiers. A buyer can therefore check a seller's CBHS deposits against a published number.

It gets documented, reviewed, and re-tiered

• Daily logs. To use Medicaid dollars, HCA and the managed care organizations need to verify that services were provided, so providers keep a log of supportive supervision for each day of service. Industry guidance is that the average hours delivered each month should align with the resident's authorized tier.
• Yearly review. Eligibility is reviewed at least once every 12 months. A resident who stabilizes may be moved to a lower tier.
• Re-tiering. A home that believes a resident is in the wrong tier can submit a Supportive Supervision Re-Tiering Request to the payer, documenting how the resident's needs have changed.
• It leaves with the resident. If a resident with a tier moves out, that income goes too.

For all of those reasons, annualizing last month's CBHS deposits overstates what a buyer can count on.

When the home is sold

DSHS staff answered this in writing in October 2026.

• The authorization stays with the resident. A resident already receiving CBHS does not need a new eligibility assessment or a new authorization because the home has a new owner. The resident's DSHS case manager notifies the managed care plan that the provider has changed, and the plan contacts the new owner about contracting.
• The new owner needs its own paperwork. To be paid without a gap, the new owner completes an application with the Health Care Authority and contracts with the managed care plan. A home whose CBHS residents are in different plans needs a contract with each.
• The order is fixed. The buyer can file the HCA application before closing and should say on it that the buyer is going through a change of ownership and contracting with DSHS. HCA usually does not approve it until the new owner's DSHS contract is in place, and the plans do not start contracting until the HCA application is in place.

In practice: a buyer should file with HCA as early as the change-of-ownership process allows, and ask each plan how long contracting takes once the license and DSHS contract are issued. Until that is known, budget for CBHS deposits to lag in the first weeks after closing.

Questions for buyers and sellers

• Which residents carry a tier, and when was each last reviewed?
• Do the daily service logs exist, and do the hours delivered line up with the tier being paid? A home paid at Tier 3 whose logs show two hours a day has a problem no buyer wants to inherit.
• What staffing is in place to deliver those hours, and what does it cost?
• How concentrated is the income: one Tier 4 resident, or several at lower tiers?
• How long will the new owner's managed care contracts take, and is payment backdated to the new license date? Ask each resident's managed care plan before relying on the income in the first months after closing.

Sellers: having those answers organized before you list makes the income credible to a buyer's lender. See How to Finance an Adult Family Home for how lenders test a home's income.

Where CBHS fits

CBHS is now the state's primary route for paying behavioral support in an adult family home. For care plans from eligibility assessments on or after July 1, 2025, a resident must first be found not eligible for CBHS before receiving Specialized Behavior Support (SBS) under the Residential Support Waiver, so the two do not stack. CBHS sits on top of the base Medicaid rate set by the resident's CARE classification (A through E), and it is separate again from owner-held specialty contracts such as ECS and SBS, which do not transfer in a sale. The Field Guide lays all four systems side by side.

This page is general educational information for people buying, selling, or operating an adult family home. It is not legal, financial, clinical, or reimbursement advice. Rates shown are the negotiated per diems in effect through June 30, 2027; tier and eligibility are decided by the Health Care Authority and the managed care organizations, not by this page. Confirm current rules, rates, and contracting requirements with the Washington State Health Care Authority and the relevant managed care organizations.