Maryland - Assisted Living Facility — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Maryland Department of Health (MDH) Office of Health Care Quality (OHCQ) licenses Assisted Living Programs under COMAR 10.07.14, while the Medicaid Community Options (CO) Waiver and Increased Community Services (ICS) Program fund the service for eligible participants. Facilities are licensed across three levels of care based on resident acuity: Level 1 (low), Level 2 (moderate), and Level 3 (high).

Medicaid waiver reimbursement is strictly limited to facilities licensed for Level 2 or Level 3 care; Level 1 programs are explicitly excluded from Medicaid waiver coverage. Applicants must secure full OHCQ licensure at the appropriate care level before initiating Medicaid enrollment through the state's electronic Provider Revalidation and Enrollment Portal (ePREP).

1. Service Definition and Scope

In Maryland, an Assisted Living Program is defined as a residential or facility-based program providing housing, supportive services, supervision, personalized assistance, and health-related services. These services are designed to meet the needs of residents who require assistance with activities of daily living (ADLs) or instrumental activities of daily living (IADLs).

The state does not specify a minimum number of residents for licensure, allowing for both small residential homes and large congregate facilities. Medicaid covers the personal care, supervision, and chore services provided within the facility, but explicitly excludes room and board costs.

• Level 1 Care: Low-level care requiring occasional assistance with two or more ADLs; not covered by Medicaid waivers.
• Level 2 Care: Moderate-level care requiring substantial assistance with ADLs; eligible for Medicaid enrollment.
• Level 3 Care: High-level care requiring extensive and frequent assistance; eligible for Medicaid enrollment.
• Excluded Services: Room and board costs are not reimbursable under the Medicaid CO or ICS waivers.

2. Regulatory and Oversight Agencies

The Maryland Department of Health (MDH) is the primary umbrella agency governing this service. Within MDH, the Office of Health Care Quality (OHCQ) handles all facility licensure, regulatory compliance, and unannounced surveys.

The MDH Medical Care Programs (Medicaid) division manages provider enrollment and waiver administration. Providers interact with Medicaid primarily through the ePREP system for enrollment and revalidation.

• Maryland Department of Health (MDH): The single state Medicaid agency (https://health.maryland.gov).
• Office of Health Care Quality (OHCQ): Licenses and surveys Assisted Living Programs (https://health.maryland.gov/ohcq).
• MDH Medicaid Provider Enrollment: Manages the ePREP portal for Medicaid participation (https://eprep.health.maryland.gov).
• Local Departments of Social Services: Administer Adult Foster Care, a separate but related residential model.

3. Gatekeeping Prerequisites: Who Can Even Apply

Maryland does not require a Certificate of Need (CON) for Assisted Living Programs, unlike comprehensive care facilities (nursing homes). There are no closed networks, moratoria, or mandatory Request for Proposal (RFP) procurements blocking initial licensure applications.

The primary structural precondition for Medicaid enrollment is holding an active OHCQ license specifically for Level 2 or Level 3 care. Facilities licensed only for Level 1 cannot be enrolled in the Medicaid Community Options Waiver.

• Certificate of Need: Genuinely none exists for Assisted Living Programs in Maryland.
• Licensure Level Prerequisite: Must hold a Level 2 or Level 3 OHCQ license to apply for Medicaid waiver enrollment.
• Zoning Approval: Written approval from the local zoning authority must be submitted before OHCQ approves initial facility drawings.
• Financial Viability: Applicants must submit an audited financial statement to OHCQ demonstrating administrative and financial ability to maintain the facility.

4. Licensure and Certification Requirements

Prospective providers must submit a comprehensive application to OHCQ, including detailed disclosures of ownership, management companies, and real property. The application must be filed at least 60 days before the anticipated issuance of the license.

Facilities must pass a life safety inspection by the State Fire Marshal and an initial on-site survey by OHCQ. The state limits the number of waivers granted to facilities regarding specific physical plant requirements.

• Application Form: Submitted to OHCQ with required ownership and management disclosures.
• Zoning and Fire Safety: Requires documented local zoning approval and State Fire Marshal clearance.
• Disclosure Form: Must complete a Department-approved Assisted Living Disclosure Form detailing services provided.
• Electronic Monitoring Waiver: Facilities must apply for a specific OHCQ waiver to use electronic monitoring in place of awake overnight staff.

5. Medicaid Provider Enrollment

Once licensed by OHCQ, the facility must enroll as a Medicaid provider using the electronic Provider Revalidation and Enrollment Portal (ePREP). The facility must enroll under the specific waiver program (e.g., Community Options Waiver).

Providers must sign a Medicaid provider agreement and comply with all federal HCBS settings rules, ensuring the facility integrates residents into the broader community and respects resident autonomy.

• Enrollment Portal: All applications must be submitted through ePREP (https://eprep.health.maryland.gov).
• Required Documentation: Must upload the active OHCQ Level 2 or 3 license and NPI number.
• HCBS Settings Rule: Must attest to and demonstrate compliance with federal community integration standards.
• Revalidation: Providers must revalidate their Medicaid enrollment through ePREP every five years.

6. Staffing, Training and Background Checks

Maryland mandates specific training and background checks for all assisted living staff. Managers of facilities with five or more residents must complete an 80-hour assisted living manager training course approved by the Department.

All staff must undergo criminal history records checks through the Maryland Department of Public Safety and Correctional Services (CJIS). Awake overnight staff are required unless a specific waiver is granted or resident assessments document no need.

• Manager Training: Managers of 5+ bed facilities must complete 20 hours of Department-approved continuing education every 2 years.
• Staff Training: Initial and ongoing training required in fire safety, infection control, basic first-aid, and resident rights.
• Background Checks: Mandatory state and federal criminal history checks via CJIS for all direct care staff.
• Medication Administration: Staff administering medications must have passed a Maryland Board of Nursing approved program.

7. Documentation, Policies and Records

Facilities must maintain comprehensive resident agreements and service plans. The resident agreement must detail the facility's licensed level of care, services provided, rate and refund policies, and grievance procedures.

Service plans must be individualized, reflecting the resident's needs and preferences, and must be updated when a resident's condition changes significantly. The Department-approved Disclosure Form must be included in all marketing materials.

• Resident Agreement: Must include financial information, discharge policies, and a recommendation for attorney review.
• Disclosure Form: Must be provided to consumers upon request and reviewed during OHCQ surveys.
• Service Plans: Must document the need for awake overnight staff based on resident assessments.
• Clinical Records: Must track medication administration, physician orders, and quarterly reviews of self-administration abilities.

8. Billing, Rates and Claims

Medicaid reimburses Assisted Living Programs on a per-diem basis for the personal care and supportive services provided. A 'unit of service' is defined as a day of service, excluding days the participant is hospitalized or absent for more than 7 nights in a month.

Providers bill through the state's MMIS system. Because Medicaid does not cover room and board, facilities must collect these costs directly from the resident's income (e.g., SSI or Social Security), minus a state-mandated personal needs allowance.

• Unit of Service: Billed as a daily rate; excludes hospital days or extended personal absences.
• Room and Board: Explicitly excluded from Medicaid reimbursement under COMAR 10.09.81.37.
• Claims Portal: Claims are submitted electronically via the Maryland Medicaid MMIS/ePREP system.
• Personal Needs Allowance: Residents must be allowed to retain a state-defined monthly allowance from their income.

9. Approval Sequence and Timeline

The approval process begins with local zoning and fire marshal clearances, followed by the submission of the OHCQ licensure application at least 60 days prior to the planned opening. OHCQ reviews the application, financial statements, and disclosure forms.

After passing the initial OHCQ on-site survey and receiving the license, the provider submits the Medicaid enrollment application via ePREP. ePREP processing typically takes 30 to 60 days, provided all documentation is complete.

• Step 1: Obtain local zoning approval and State Fire Marshal clearance.
• Step 2: Submit OHCQ application at least 60 days before anticipated opening.
• Step 3: Pass OHCQ initial on-site life safety and health survey.
• Step 4: Submit Medicaid enrollment application via ePREP with the active license.

10. Common Denials and Survey Findings

OHCQ frequently cites facilities for incomplete or inaccurate resident agreements and failure to update service plans when a resident's condition changes. Medication administration errors are also a primary source of survey deficiencies.

Medicaid enrollment applications in ePREP are commonly delayed or denied due to mismatched NPI data, failure to upload the correct Level 2 or 3 OHCQ license, or incomplete ownership disclosures.

• Resident Agreements: Cited for lacking required financial disclosures or attorney review recommendations.
• Medication Errors: Deficiencies issued for staff administering medications without Board of Nursing certification.
• Staffing Ratios: Cited for lacking awake overnight staff without an approved electronic monitoring waiver.
• ePREP Denials: Applications rejected for missing ownership details or uploading a Level 1 license.

11. Key Contacts and Resources

Providers must maintain contact with OHCQ for all licensure and regulatory matters, and with MDH Medicaid for billing and enrollment issues. The ePREP portal is the central hub for all Medicaid provider file maintenance.

Local zoning boards and the State Fire Marshal are critical contacts during the initial physical plant approval phase.

• MDH Office of Health Care Quality (OHCQ): https://health.maryland.gov/ohcq
• Maryland Medicaid ePREP Portal: https://eprep.health.maryland.gov
• Maryland Department of Health (MDH): https://health.maryland.gov
• Code of Maryland Regulations (COMAR): Title 10, Subtitle 07, Chapter 14 (Assisted Living Programs).

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