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

Last reviewed: 2026-08-16

In Maryland, Assisted Living Facilities are officially licensed as Assisted Living Programs (ALPs) by the Maryland Department of Health (MDH) Office of Health Care Quality (OHCQ). These congregate residential programs provide housing, supervision, personalized assistance, and health-related services to individuals needing help with activities of daily living. For Medicaid reimbursement, licensed ALPs enroll as providers under the state's Home and Community-Based Options Waiver (HCBS Options Waiver), which funds services for low-income adults at risk of nursing home placement.

The single biggest structural barrier to entry in Maryland is not a state-level Certificate of Need (CON), which is not required for ALPs, but rather strict local zoning approvals and upfront financial prerequisites. OHCQ will not process a licensure application without prior county or city zoning approval, a comprehensive business plan, and a detailed 1-year operating budget. Furthermore, Medicaid provider enrollment operates on a strict sequential gate: a facility cannot even begin the Medicaid enrollment process until it has fully secured its OHCQ license.

1. Service Definition and Scope

Under the Code of Maryland Regulations (COMAR) 10.07.14, an Assisted Living Program is defined as a residential or facility-based program for two or more residents that provides long-term housing, supportive services, supervision, and personalized assistance. Facilities are licensed based on three distinct levels of care, which dictate the acuity of residents they are legally permitted to serve.

Medicaid covers assisted living services through the HCBS Options Waiver. This waiver pays for the care and supportive services provided within the facility, though it strictly prohibits the use of Medicaid funds for room and board, which the resident must cover using personal income such as Supplemental Security Income (SSI).

• Regulatory Term: Assisted Living Program (ALP).
• Minimum Size: Must serve two or more residents; single-resident homes do not qualify for this specific licensure.
• Levels of Care: Licensed for Level 1 (Low), Level 2 (Moderate), or Level 3 (High) based on resident acuity and staff capabilities.
• Service Limitations: Facilities are strictly prohibited from admitting individuals requiring ventilator services, treatment of stage III or IV skin ulcers, or more than intermittent nursing care.
• Medicaid Vehicle: Home and Community-Based Options Waiver (HCBS Options Waiver).
• Excluded Entities: Nursing homes, state facilities, and licensed residential service agencies providing care in an individual's own home are regulated under separate authorities.

2. Regulatory and Oversight Agencies

The Maryland Department of Health (MDH) is the primary umbrella agency governing assisted living. Within MDH, the Office of Health Care Quality (OHCQ) is the specific division responsible for licensing, regulating, and surveying Assisted Living Programs.

Medicaid enrollment and claims are managed by MDH's Medical Care Programs (MMCP) division. Additionally, local county agencies play a significant role in the initial approval and ongoing monitoring of these facilities.

• Licensing Authority: MDH Office of Health Care Quality (OHCQ) - Assisted Living Unit.
• Medicaid Authority: MDH Medical Care Programs (MMCP).
• Nursing Oversight: Maryland Board of Nursing (regulates the Delegating Nurse Model and Certified Medication Technicians).
• Local Environmental Oversight: County or City Health Departments (issue food service permits and conduct environmental inspections).
• Abuse Investigations: Local Departments of Social Services (DSS) and Adult Protective Services (APS).

3. Gatekeeping Prerequisites: Who Can Even Apply

Maryland does not require a Certificate of Need (CON) for Assisted Living Programs, nor does it utilize Request for Proposals (RFPs), closed networks, or moratoria for Medicaid HCBS Options Waiver provider enrollment. The state operates an open enrollment model for qualified, licensed providers.

However, there are absolute structural preconditions that block an application from being accepted. An applicant cannot submit an OHCQ application without prior local zoning approval and proof of financial viability. Medicaid enrollment is strictly gated behind the issuance of the OHCQ license.

• Certificate of Need (CON): Not required for Assisted Living Programs in Maryland (unlike nursing homes).
• Procurement/RFP: None; Medicaid waiver enrollment is open to any OHCQ-licensed provider meeting waiver standards.
• Local Zoning Approval: Mandatory prerequisite; applicants must secure county/city zoning and use permits before OHCQ will accept a licensure application.
• Financial Prerequisite: Applicants must submit a formal business plan and a 1-year operating budget with the initial OHCQ application.
• Medicaid Prerequisite: Providers must hold an active, unencumbered OHCQ Assisted Living Program license before initiating an application in the Medicaid provider portal.

4. Licensure and Certification Requirements

The licensure process is managed entirely by OHCQ. Applicants must complete the official Assisted Living Program Licensure Application, which must be typed using a PDF application; handwritten applications are automatically rejected and returned.

Applications and all required attachments must be submitted electronically via OHCQ's designated Smartsheet portal. Fees are assessed based on the requested bed capacity of the facility.

• Application Form: OHCQ Assisted Living Program Licensure Application (PDF format).
• Submission Portal: OHCQ Smartsheet link (Submit a License Application).
• Regulation Citation: COMAR 10.07.14.
• Required Attachments: Ownership disclosures, business plan, 1-year operating budget, and comprehensive policies and procedures.
• Local Permits Required: Facility plan review documentation and a local food service permit.
• Insurance Requirement: Verification of active Workers' Compensation insurance.

5. Medicaid Provider Enrollment

Once licensed by OHCQ, facilities wishing to serve Medicaid waiver participants must enroll as participating providers through the state's Medicaid provider enrollment portal. Maryland is currently undergoing a major system transition for provider enrollment.

Providers currently use the ePREP system, but MDH is transitioning to the Maryland Provider Registration and Information Management Enterprise (MPRIME) portal in October 2026. Approval results in the issuance of a Medicaid Provider Identification Number (PID).

• Current Enrollment Portal: ePREP (Electronic Provider Revalidation and Enrollment Portal).
• Future Enrollment Portal: MPRIME (launching October 2026).
• Target Waiver: Home and Community-Based Options Waiver.
• Provider Identifier: Issuance of a Medicaid Provider Identification Number (PID) upon approval.
• System Integration: Enrollment registers the provider in the Maryland Medicaid Management Information System (MMIS) for claims processing.

6. Staffing, Training and Background Checks

Maryland enforces strict training and credentialing standards for assisted living staff, particularly concerning facility management and medication administration. The facility must be managed by a qualified Assisted Living Manager (ALM).

Medication administration operates under Maryland's Delegating Nurse Model, requiring specific coordination between registered nurses and unlicensed direct care staff.

• Administrator Training: The Assisted Living Manager must complete an 80-hour manager course approved by OHCQ.
• Medication Administration: Unlicensed staff must complete the Certified Medication Technician (CMT) course.
• Nursing Delegation: CMTs must be taught and supervised by a Registered Nurse (RN) approved by the Maryland Board of Nursing under the Delegating Nurse Model.
• Background Checks: Criminal background checks are mandatory for all owners and staff prior to employment or facility operation.
• Specialized Training: Mandatory cognitive impairment and Alzheimer's training is required for all staff.
• Staffing Plan: Facilities must maintain a documented staffing plan identifying the type and number of staff needed based on resident acuity.

7. Documentation, Policies and Records

COMAR 10.07.14 dictates extensive documentation requirements for resident admissions, care planning, and facility transparency. Facilities must maintain individualized records that reflect actual practices and resident needs.

Public posting of specific regulatory documents is mandatory to ensure transparency for residents and their families.

• Resident Agreement: Must be written in plain English, detailing all services, rates, and actual facility practices prior to admission.
• Service Plans: Individualized service plans must be developed for all residents based on a comprehensive health and functional assessment.
• Alzheimer's Disclosure: Facilities marketing dementia care must submit and maintain a New Alzheimer's Special Care Unit Disclosure Form.
• Public Postings: Facilities must publicly post their current OHCQ license, the most recent survey/inspection results, and resident rights information.
• Change Requests: Bed increases, level of care increases, or name changes must be submitted via specific OHCQ Smartsheet forms.

8. Billing, Rates and Claims

Medicaid billing for the HCBS Options Waiver is processed through the state's Medicaid Management Information System (MMIS). Providers must verify participant eligibility and secure service authorizations before billing.

Case management and service tracking for waiver participants are handled through a separate state system, requiring providers to interface with multiple platforms to ensure compliant reimbursement.

• Claims System: Maryland Medicaid Management Information System (MMIS).
• Case Management System: LTSSMaryland (Long Term Services and Supports) is used for tracking waiver service authorizations.
• Eligibility Verification: Providers must use the Eligibility Verification System (EVS) to confirm active Medicaid status.
• Room and Board: Medicaid does not pay for room and board; providers must collect this directly from the resident's personal funds.
• Participant Financial Limits: Waiver participants must meet strict financial eligibility, including a maximum asset limit of $11,000 for single adults.

9. Approval Sequence and Timeline

Becoming a Medicaid-enrolled Assisted Living Program in Maryland is a sequential process that begins at the local municipal level and ends with state Medicaid portal enrollment. Steps cannot be taken out of order.

The timeline is heavily dependent on local zoning boards and the completion of the mandatory 80-hour manager training before OHCQ will even review the licensure application.

• Step 1: Form the business entity, obtain an EIN, and secure local county/city zoning and use approvals.
• Step 2: The designated administrator completes the OHCQ-approved 80-hour Assisted Living Manager course.
• Step 3: Submit the typed OHCQ licensure application via Smartsheet, including the business plan, budget, and licensing fees.
• Step 4: OHCQ reviews the application and conducts an initial on-site life safety and health inspection.
• Step 5: OHCQ issues the Assisted Living Program license.
• Step 6: Submit the Medicaid provider enrollment application via ePREP (or MPRIME) to receive a PID and begin billing.

10. Common Denials and Survey Findings

OHCQ frequently rejects initial applications for administrative errors, such as submitting handwritten forms or failing to include local zoning approvals. During on-site surveys, citations often revolve around medication management and life safety.

Medicaid enrollment denials typically occur when a facility attempts to apply before their OHCQ license is fully active or if ownership background checks reveal disqualifying offenses.

• Application Rejection: Handwritten OHCQ applications are automatically rejected and returned to the applicant.
• Zoning Failures: Inability to provide documented local zoning approval halts the OHCQ application process immediately.
• Medication Errors: Frequent survey citations for failing to properly document delegated nursing tasks or lapsed CMT certifications.
• Fire Safety Violations: Citations for expired fire extinguisher servicing or lack of documented annual staff fire training.
• Scope of Practice Violations: Admitting or retaining residents who require skilled nursing care (e.g., stage III/IV ulcers) beyond the facility's licensed level of care.

11. Key Contacts and Resources

Prospective providers must interact with several state portals and regulatory bodies. The MDH website serves as the central hub for both OHCQ licensing and MMCP Medicaid enrollment.

Familiarity with the specific COMAR regulations and the upcoming MPRIME transition is essential for maintaining compliance and uninterrupted billing.

• Licensing Agency: MDH Office of Health Care Quality (OHCQ) - Assisted Living Unit.
• Medicaid Enrollment: MDH Medical Care Programs (MMCP) Provider Enrollment.
• Application Portal: OHCQ Smartsheet (Submit a License Application link).
• Medicaid Portal: ePREP (transitioning to MPRIME in October 2026).
• Regulations: Code of Maryland Regulations (COMAR) 10.07.14 (Assisted Living Programs).
• Case Management Portal: LTSSMaryland Training Center and system access.

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