Understanding CalAIM Care Tiers and ADLs: What Families and Professionals Need to Know

One of the most common areas of confusion when navigating long-term care in California is how care “tiers” and Activities of Daily Living (ADLs) are defined under the CalAIM program. Many families—and even some professionals—assume there is a standardized system that clearly assigns individuals to specific tiers based on ADLs.

The reality is more nuanced.

CalAIM does not officially publish standardized tier levels tied directly to ADLs. What most providers are referring to when they discuss “tiers” are actually two overlapping—but distinct—systems:

• The Assisted Living Waiver (ALW) care tiers (typically Tier 1–3, sometimes Tier 4)

• Provider-created care levels used within CalAIM Community Supports

While these systems often look similar, they are not identical and should not be used interchangeably.

What ADLs Are Being Measured?

Both ALW and CalAIM rely on the same foundational Activities of Daily Living (ADLs) to assess a person’s care needs. These include:

• Bathing

• Dressing

• Toileting

• Transferring (bed to chair)

• Eating

• Continence

In addition to ADLs, CalAIM assessments may also evaluate Instrumental Activities of Daily Living (IADLs), which reflect a person’s ability to live independently. These may include:

• Cooking

• Shopping

• Transportation

• Medication management

Together, ADLs and IADLs provide a comprehensive picture of an individual’s functional abilities.

How Tier Levels Actually Work Under CalAIM

A key distinction is that CalAIM does not assign universal care tiers across the state.

Instead, the process works like this:

• Managed Care Plans evaluate and authorize services based on functional need

• Assisted living providers (or ALW structures) then translate that need into internal care levels or tiers

• The greater the assistance required with ADLs, the higher the level of care assigned

In simple terms, tiers are function-based—not state-defined labels.

Typical Tier Structure Used in Practice

Even though there is no official statewide tier system under CalAIM, most assisted living providers and residential care facilities follow a similar structure:

Tier 1 – Minimal Assistance

Individuals at this level are largely independent.

ADL Profile:

• Independent in most ADLs

• May need cueing, reminders, or standby assistance

Common Needs:

• Medication reminders

• Supervision for bathing

• Light assistance with dressing

Typically reflects 0–1 ADLs requiring hands-on help

Tier 2 – Moderate Assistance

Residents begin to require more consistent, hands-on support.

ADL Profile:

• Needs assistance with multiple ADLs

Common Needs:

• Help with bathing and dressing

• Assistance with transferring (some weight-bearing)

• Toileting support

Typically reflects 2–3 ADLs requiring assistance

Tier 3 – Extensive Assistance

This level involves significant physical or cognitive limitations.

ADL Profile:

• Requires help with most ADLs

Common Needs:

• Assistance with the majority of daily activities

• Frequent incontinence care

• Mobility support (sometimes two-person assist)

• Dementia-related supervision

Typically reflects 4–5 ADLs requiring hands-on care

Tier 4 – Total Care / High Acuity (When Used)

Not all providers use a Tier 4, but when they do, it represents the highest level of care.

ADL Profile:

• Dependent in nearly all ADLs

Common Needs:

• Full assistance with eating, toileting, and transfers

• Bedbound or near-bedbound status

• Complex medical or behavioral needs

Typically reflects 5–6 ADLs with full dependence

What CalAIM Specifically Requires

Under CalAIM Community Supports, individuals generally must meet a “nursing facility level of care.” This means:

• Assistance is needed with multiple ADLs and/or IADLs

• Medication oversight is required

• 24-hour supervision may be necessary

However, it’s important to emphasize:

CalAIM does not define care using rigid formulas such as:

• “Tier 1 = 2 ADLs”

• “Tier 2 = 4 ADLs”

Those classifications are created by providers or waiver program structures—not the state.

Key Difference: ALW vs. CalAIM

Understanding the distinction between these two systems is critical:

• Assisted Living Waiver (ALW):
  Uses fixed, state-recognized tiers tied to reimbursement levels

• CalAIM:
  Uses a flexible, needs-based authorization model, where providers assign internal care levels

In practice, this means:

• Under ALW: “You are approved for Tier 2.”

• Under CalAIM: “You are approved for a certain level of care,” and the facility determines the tier internally

How to Explain This Simply to Families

When speaking with families or referral partners, clarity is key. A simple way to explain it is:

“CalAIM doesn’t assign tiers directly—it evaluates how much help someone needs with daily activities. The care provider then places them into a level or tier based on that need.”

A Practical Shortcut for Professionals

While not official, many residential care facilities in California follow this general guideline:

• Tier 1: 0–1 ADLs

• Tier 2: 2–3 ADLs

• Tier 3: 4+ ADLs

This can be a helpful reference point when discussing care needs—but it’s important to always verify how each provider defines their levels, as there can be variation.

Final Thoughts

Navigating CalAIM and care tiers can feel overwhelming, especially when terminology is used inconsistently across providers. The most important takeaway is this:

Care levels are driven by functional need—not fixed labels.

By focusing on how many ADLs a person needs help with—and the type of assistance required—you can more accurately understand placement options, set expectations, and guide families toward the right level of care.