Maryland - Adult Companion Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

Maryland does not license or enroll providers under a distinct "Adult Companion Services" category. Instead, non-medical supervision, socialization, and assistance that allow adults to remain safely in the community are covered as Personal Assistance Services under the Community Options Waiver and CPAS, or as Personal Supports under Developmental Disabilities Administration (DDA) waivers. To provide these services legally, an agency must be licensed as a Residential Service Agency (RSA) by the Maryland Department of Health (MDH).

The single biggest structural barrier to entry is the mandatory RSA licensure through the MDH Office of Health Care Quality (OHCQ) prior to Medicaid enrollment. This gatekeeping step requires securing a Maryland-licensed Registered Nurse (RN) as a clinical director, leasing a compliant commercial office space, and passing a rigorous pre-licensure site survey before an application to Medicaid's ePREP system can even be initiated.

1. Service Definition and Scope

Because Maryland lacks a standalone companion care license, providers operate under the Residential Service Agency (RSA) framework. RSAs provide non-medical in-home care, which encompasses the supervision, socialization, and light assistance typically associated with companion services.

These services are designed to prevent institutionalization by supporting individuals in their homes. While companions cannot perform skilled nursing tasks, they are authorized to assist with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) under RN supervision.

• Service Umbrella: covered as Personal Assistance Services (Community Options Waiver) or Personal Supports (DDA Waivers) rather than standalone companion care.
• Licensure Category: requires a Residential Service Agency (RSA) Level 1 (non-complex) or Level 3 (complex/Medicaid) license from OHCQ.
• Scope of Practice: includes non-medical supervision, socialization, meal preparation, light housekeeping, and assistance with ADLs.
• Excluded Services: strictly prohibits skilled nursing, wound care, and medication administration unless specifically delegated by an RN under a Level 3 license.
• Target Population: serves elderly adults, individuals with physical disabilities, and individuals with intellectual or developmental disabilities.

2. Regulatory and Oversight Agencies

The Maryland Department of Health (MDH) is the umbrella agency governing all Medicaid and HCBS services. Within MDH, responsibilities are divided among specialized divisions that handle licensing, enrollment, and waiver administration.

Providers must interact with multiple state entities simultaneously, ensuring compliance with health care quality standards, Medicaid billing rules, and specific waiver program guidelines.

• Licensing Authority: MDH Office of Health Care Quality (OHCQ) issues the RSA license and conducts surveys.
• Medicaid Enrollment: MDH Provider Enrollment Division manages the ePREP portal for Medicaid participation.
• Waiver Administration (Aging/Physical): MDH Office of Long Term Services and Supports (OLTSS) administers the Community Options Waiver and CPAS.
• Waiver Administration (ID/DD): MDH Developmental Disabilities Administration (DDA) oversees waivers for individuals with developmental disabilities.
• Background Checks: Maryland Department of Public Safety and Correctional Services (DPSCS) processes mandatory fingerprinting.

3. Gatekeeping Prerequisites: Who Can Even Apply

Maryland enforces strict structural preconditions that block applicants from entering the Medicaid system prematurely. You cannot simply apply to be a Medicaid provider; you must first build a fully compliant, licensed agency.

The most critical gate is the OHCQ RSA license. Without this active license, the Medicaid enrollment portal will automatically reject the application. Furthermore, serving the DDA population requires an entirely separate pre-approval process.

• Licensure Prerequisite: must obtain an active Residential Service Agency (RSA) license from OHCQ before initiating Medicaid enrollment.
• Clinical Leadership: must employ a Maryland-licensed Registered Nurse (RN) as the Clinical Director/Supervising Nurse prior to submitting the OHCQ application.
• Physical Location: must secure a commercial office space in Maryland that meets local zoning and fire marshal approval; home offices are prohibited.
• DDA Pre-Approval: if targeting DDA waivers, requires a completed DDA Provider Application and regional office sponsorship before Medicaid enrollment.
• NPI Requirement: must obtain a Type 2 National Provider Identifier (NPI) linked to the exact legal business name registered with the state.

4. Licensure and Certification Requirements

The pathway to providing companion-style services begins with the OHCQ RSA application. This process is governed by the Code of Maryland Regulations (COMAR) and requires a comprehensive review of the agency's structure and policies.

Applicants must submit a detailed application packet, pay a non-refundable fee, and pass an on-site inspection where surveyors verify that the agency is fully prepared to operate safely.

• Regulatory Citation: governed by COMAR 10.07.05 (Residential Service Agencies).
• Application Form: requires submission of the OHCQ RSA Initial Application along with a $2,000 initial licensing fee.
• Business Registration: requires a Certificate of Good Standing from the Maryland State Department of Assessments and Taxation (SDAT).
• Workers' Compensation: requires proof of coverage or a valid binder from Chesapeake Employers' Insurance Company or a private carrier.
• Pre-Licensure Survey: mandates an on-site inspection by OHCQ surveyors to review policies, personnel files, and the physical office space.

5. Medicaid Provider Enrollment

Once licensed by OHCQ, the agency must enroll as a Medicaid provider to bill for waiver services. This is currently done through the electronic Provider Revalidation and Enrollment Portal (ePREP).

Maryland is in the process of upgrading its enrollment infrastructure. Providers must ensure all data in the portal perfectly matches their SDAT registration, IRS documentation, and OHCQ license.

• Enrollment Portal: utilizes the Maryland Medicaid electronic Provider Revalidation and Enrollment Portal (ePREP).
• Future System: transitioning to the Maryland Provider Registration and Information Management Enterprise (MPRIME) in October 2026.
• Provider Type: enrolls as Provider Type 85 (Personal Care) or specific DDA provider types depending on the target waiver.
• Application Fee: subject to the ACA institutional provider application fee (approximately $731) unless waived by prior Medicare enrollment.
• System Integration: requires registration with LTSSMaryland for waiver billing, care plan access, and Electronic Visit Verification (EVV).

6. Staffing, Training and Background Checks

Direct care workers providing companion and personal assistance services must meet strict state standards before they can enter a client's home. Agencies are responsible for verifying all credentials.

The supervising RN plays a critical role in this process, as they must assess the client, develop the care plan, and ensure the assigned aide is competent to perform the required tasks.

• Background Checks: mandates fingerprint-based state and FBI criminal history records checks via the Criminal Justice Information System (CJIS).
• Registry Checks: requires clearance through the Maryland Certified Nursing Assistant (CNA) registry and the federal Medicaid Exclusion List.
• Basic Qualifications: mandates current CPR and First Aid certification from an accredited source (e.g., American Heart Association, Red Cross).
• Training Requirements: requires minimum hours of initial training covering HIPAA, infection control, client rights, and emergency procedures per COMAR.
• Supervision: requires the RN to conduct an initial in-home assessment and supervise the companion/aide on-site every 60 to 90 days.

7. Documentation, Policies and Records

Maryland requires RSAs to maintain extensive documentation to prove ongoing compliance with COMAR and Medicaid regulations. A robust policy manual is the foundation of a successful agency.

During annual surveys, OHCQ will audit personnel files, client care plans, and service logs to ensure that the agency is following its own policies and state laws.

• Policy Manual: must include comprehensive protocols for emergency preparedness, infection control, and abuse/neglect reporting.
• Care Plans: requires an Individualized Plan of Care (POC) developed by the RN and approved by the waiver case manager.
• Personnel Files: must contain I-9s, CJIS background check results, CPR/First Aid cards, and annual performance evaluations.
• Service Logs: mandates Electronic Visit Verification (EVV) records capturing exact clock-in/clock-out times and specific tasks completed.
• Incident Reporting: requires mandatory reporting of critical incidents to OHCQ and OLTSS/DDA within 24 hours of occurrence.

8. Billing, Rates and Claims

Medicaid billing for HCBS in Maryland is highly automated and strictly tied to prior authorizations. Providers cannot bill for services that exceed the hours approved in the participant's care plan.

The state utilizes a mandatory Electronic Visit Verification (EVV) system to ensure that services were actually delivered in the home before a claim is paid.

• Billing System: processes claims through the Medicaid Management Information System (MMIS) via the LTSSMaryland portal.
• EVV Mandate: requires the use of the In-Home Supports Assurance System (ISAS) or a compatible EVV system for all personal care/companion claims.
• Reimbursement Rates: established by MDH and typically billed in 15-minute increments using specific HCPCS codes (e.g., T1019).
• Prior Authorization: mandates that services be explicitly authorized on the participant's approved Plan of Service in LTSSMaryland before billing.
• Payment Cycle: pays clean claims on a weekly cycle via Electronic Funds Transfer (EFT).

9. Approval Sequence and Timeline

Becoming a fully operational Medicaid provider in Maryland is a sequential process that typically takes 6 to 9 months from start to finish. Steps cannot be taken out of order.

Delays in securing a commercial office, hiring an RN, or passing the OHCQ survey will significantly extend the timeline.

• Step 1: complete SDAT business registration, obtain an EIN, and secure a Type 2 NPI (1-2 weeks).
• Step 2: secure a commercial office, hire an RN, and submit the OHCQ RSA application with the $2,000 fee (4-8 weeks for initial review).
• Step 3: pass the OHCQ pre-licensure site survey and receive the official RSA license (2-3 months).
• Step 4: submit the Medicaid enrollment application via ePREP using the new RSA license (60-90 days for approval).
• Step 5: complete LTSSMaryland registration and EVV system setup to begin accepting client referrals (2-4 weeks post-enrollment).

10. Common Denials and Survey Findings

Many applicants fail the initial OHCQ survey or face ePREP rejections due to administrative oversights. Attention to detail is critical when matching documents across state systems.

Surveyors frequently cite agencies for failing to customize their policy manuals to Maryland's specific COMAR regulations, relying instead on generic national templates.

• Incomplete Policies: submitting generic policy manuals that do not specifically reference Maryland COMAR 10.07.05 regulations.
• Zoning Issues: failing to obtain local use-and-occupancy permits for the commercial office space prior to the OHCQ survey.
• Background Check Gaps: allowing staff to provide services before CJIS fingerprint results are fully returned and reviewed.
• RN Absence: failing to replace the designated Clinical Director (RN) within the required timeframe if they leave the agency.
• ePREP Errors: submitting applications with mismatched legal business names between SDAT, IRS (EIN), NPI, and the OHCQ license.

11. Key Contacts and Resources

Navigating the Maryland Medicaid and licensing landscape requires direct communication with several state departments. Providers should bookmark the official portals and regulatory codes.

Utilizing the correct help desks for ePREP and LTSSMaryland can resolve technical enrollment and billing issues much faster than general inquiries.

• Licensing: MDH Office of Health Care Quality (OHCQ) - RSA Unit for licensure applications and survey questions.
• Medicaid Enrollment: MDH Provider Enrollment Division for ePREP and upcoming MPRIME portal support.
• Waiver Administration: MDH Office of Long Term Services and Supports (OLTSS) for Community Options Waiver policies.
• Background Checks: Maryland Department of Public Safety and Correctional Services (DPSCS) - CJIS for fingerprinting.
• Business Registration: Maryland State Department of Assessments and Taxation (SDAT) for corporate standing and entity formation.

See all Maryland services · Maryland Medicaid consulting · book a consultation.