Maryland - Skilled Nursing Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Maryland Department of Health’s Office of Health Care Quality (OHCQ) licenses in-home RN and LPN care under two distinct authorities: as a Home Health Agency (HHA) or as a Residential Service Agency (RSA) with a Skilled Nursing and Aide Services classification.

Agencies seeking to bill Maryland Medicaid waiver programs for skilled nursing typically pursue the RSA Level 1 or Level 2 license, as establishing a new HHA requires a Certificate of Need (CON) from the Maryland Health Care Commission. Approved RSAs enroll through the ePREP portal to serve participants in the Community Pathways and Home and Community-Based Options waivers.

1. Service Definition and Scope

In Maryland, Medicaid waiver skilled nursing services consist of direct clinical care provided in the participant's home by a Registered Nurse (RN) or Licensed Practical Nurse (LPN). These services are designed for individuals with complex medical needs who require care beyond the scope of standard personal care aides.

Under the RSA framework, providers must hold specific licensure levels to deliver these services. The scope includes comprehensive assessments, medication administration, wound care, and ventilator management, all executed under active physician orders.

• Service Modality: In-home skilled nursing care delivered by RNs or LPNs under the supervision of an RN.
• RSA Classification: Level 1 (complex nursing) or Level 2 (basic nursing) licensure is required for Medicaid waiver billing.
• Physician Orders: Services must be ordered by a Maryland-licensed physician and documented in the participant's Person-Centered Plan of Care.
• Covered Tasks: Medication administration, wound care, ventilator management, and comprehensive nursing assessments.
• Excluded Activities: RSAs cannot advertise as Home Health Agencies or bill Medicare for home health episodes.

2. Regulatory and Oversight Agencies

The Maryland Department of Health (MDH) divides oversight between facility licensing and Medicaid enrollment. The Office of Health Care Quality (OHCQ) handles the licensure of all home care entities.

Medicaid enrollment and claims are managed by MDH Medical Care Programs, while the Maryland Health Care Commission regulates market entry for traditional Home Health Agencies.

• Licensing Authority: Maryland Department of Health (MDH) Office of Health Care Quality (OHCQ) (https://health.maryland.gov/ohcq/Pages/home.aspx).
• CON Authority: Maryland Health Care Commission (MHCC) (https://mhcc.maryland.gov).
• Medicaid Enrollment: MDH Medical Care Programs via ePREP (https://eprep.health.maryland.gov).
• Nursing Board: Maryland Board of Nursing (MBON) (https://mbon.maryland.gov).

3. Gatekeeping Prerequisites: Who Can Even Apply

Maryland imposes a strict structural divide based on the type of agency an applicant wishes to operate. Traditional Home Health Agencies face a stringent need-review process, while Residential Service Agencies do not.

For Medicaid waiver providers, securing the RSA license from OHCQ is the mandatory first step before any Medicaid enrollment application can be initiated.

• Certificate of Need (CON): Required by MHCC (COMAR 10.24.16) only if applying as a Home Health Agency; RSAs are exempt from this requirement.
• RSA Licensure Prerequisite: An OHCQ RSA license must be fully approved and issued before a Medicaid enrollment application is accepted in ePREP.
• Business Registration: Entities must be registered and in good standing with the Maryland State Department of Assessments and Taxation (SDAT).
• Waiver Program Capacity: Maryland operates open enrollment for RSA skilled nursing providers; there are currently no moratoria or closed networks for this provider type.

4. Licensure and Certification Requirements

To provide skilled nursing without a CON, agencies must apply for a Residential Service Agency license under COMAR 10.07.05. The application requires detailed operational policies and the designation of qualified clinical leadership.

Applicants must specify their intent to provide Skilled Nursing and Aide Services and select the appropriate level of care based on the complexity of the nursing tasks they intend to perform.

• Regulation Citation: COMAR 10.07.05 governs the licensure and operation of Residential Service Agencies.
• License Categories: Applicants must apply for the "Skilled Nursing and Aide Services" classification at Level 1 or Level 2.
• Application Form: The OHCQ RSA Initial Application must be submitted with all required attachments and policy manuals.
• Licensure Fee: A $2,000 initial application fee is required, payable to the Maryland Department of Health.
• Nursing Director: The agency must designate a Maryland-licensed RN as the Director of Nursing or Clinical Director.

5. Medicaid Provider Enrollment

Once licensed by OHCQ, providers must enroll in Maryland Medicaid using the electronic Provider Revalidation and Enrollment Portal (ePREP). This system manages all provider data, affiliations, and waiver program selections.

Providers must ensure that their legal entity information in ePREP perfectly matches their SDAT registration, IRS documentation, and OHCQ license.

• Enrollment Portal: Maryland ePREP (electronic Provider Revalidation and Enrollment Portal) (https://eprep.health.maryland.gov).
• Provider Type: Agencies typically enroll under Provider Type 36 (RSA) or 27 (Home Health) depending on their specific licensure and waiver targets.
• Required Identifiers: A National Provider Identifier (NPI) and IRS Employer Identification Number (EIN) are mandatory.
• Waiver Selection: Providers must select specific programs, such as the Home and Community-Based Options Waiver, during the ePREP enrollment process.
• Revalidation: Maryland requires Medicaid providers to revalidate their enrollment every five years through ePREP.

6. Staffing, Training and Background Checks

Maryland requires all skilled nursing staff to hold active, unencumbered licenses from the Maryland Board of Nursing. Agencies are responsible for verifying credentials prior to patient contact.

Comprehensive background checks through the state's criminal justice system are mandatory for all direct care personnel.

• RN Qualifications: Must hold an active Registered Nurse license from the Maryland Board of Nursing or a recognized compact state.
• LPN Qualifications: Must hold an active LPN license and practice under the direct supervision of an RN.
• Background Checks: State and FBI criminal history records checks must be processed via the Maryland Criminal Justice Information System (CJIS).
• CPR Certification: All direct care nursing staff must hold current, in-person CPR and First Aid certification.
• Orientation Training: Staff must complete agency-specific orientation covering abuse/neglect reporting, incident management, and COMAR regulations.

7. Documentation, Policies and Records

OHCQ enforces strict clinical recordkeeping and administrative policy requirements for RSAs. Agencies must maintain comprehensive manuals that align with Maryland-specific regulations.

Clinical records must clearly demonstrate that nursing services are delivered in accordance with physician orders and the Medicaid waiver Person-Centered Service Plan.

• Clinical Records: Must maintain a patient record including physician orders, nursing assessments, and daily clinical notes.
• Plan of Care: Nursing services must align with the MDH-approved Person-Centered Service Plan.
• Policy Manual: Must submit comprehensive policies to OHCQ covering admission, discharge, emergency preparedness, and infection control.
• Incident Reporting: Mandatory reporting of critical incidents to OHCQ and the waiver operating agency within 24 hours.
• Record Retention: Medical records must be retained for a minimum of five years (or longer for minors) per Maryland law.

8. Billing, Rates and Claims

Skilled nursing services are billed to Maryland Medicaid on a fee-for-service basis using standard HCPCS codes. Claims are processed through the state's MMIS.

All waiver services require prior authorization, and providers must comply with federal Electronic Visit Verification (EVV) mandates for in-home care.

• Billing System: Claims are submitted electronically via the Maryland Medicaid Management Information System (MMIS) or an approved clearinghouse.
• Procedure Codes: Typically billed using T1002 (RN services) and T1003 (LPN services) in 15-minute increments.
• Rate Setting: MDH Medical Care Programs establishes fixed fee-for-service rates published in the annual Medicaid fee schedule.
• Prior Authorization: All waiver skilled nursing hours must be prior-authorized by the participant's Supports Planner or Coordinator.
• Electronic Visit Verification (EVV): Maryland requires EVV compliance for in-home personal care and home health services via the state's ISAS system.

9. Approval Sequence and Timeline

Becoming a skilled nursing provider in Maryland is a sequential process. Agencies cannot begin Medicaid enrollment until the OHCQ licensure phase is entirely complete.

The total timeline from entity formation to billing the first claim typically spans several months, heavily dependent on OHCQ review queues.

• Step 1: Entity formation and SDAT registration (1-2 weeks).
• Step 2: Submit RSA application and policies to OHCQ (review takes 60-90 days).
• Step 3: OHCQ issues the RSA license.
• Step 4: Submit Medicaid enrollment application via ePREP with the OHCQ license (30-60 days).
• Step 5: Receive Medicaid Provider Identification Number (PID) and begin accepting waiver authorizations.

10. Common Denials and Survey Findings

Applications are frequently delayed or denied due to incomplete policy manuals or discrepancies in legal entity documentation. OHCQ reviewers require policies to be customized to Maryland regulations, not generic templates.

During post-enrollment surveys, OHCQ commonly cites agencies for clinical documentation failures, particularly regarding physician orders.

• Policy Deficiencies: OHCQ frequently rejects RSA applications if the emergency preparedness or infection control policies lack Maryland-specific protocols.
• Director Qualifications: Denials occur if the designated RN Director lacks the required supervisory experience or active MBON licensure.
• ePREP Mismatches: Medicaid enrollment delays often stem from discrepancies between the SDAT legal name, IRS W-9, and OHCQ license.
• Survey Citations: Post-enrollment OHCQ surveys commonly cite agencies for failing to update physician orders every 60 days.

11. Key Contacts and Resources

Providers must interact with multiple state portals and agency divisions throughout the lifecycle of their business. Maintaining access to these official resources is critical for compliance.

The following links direct to the primary regulatory and enrollment bodies for Maryland skilled nursing providers.

• MDH OHCQ RSA Licensing: https://health.maryland.gov/ohcq/Pages/Residential-Service-Agencies.aspx
• Maryland ePREP Portal: https://eprep.health.maryland.gov
• Maryland Health Care Commission (CON): https://mhcc.maryland.gov
• Maryland Board of Nursing: https://mbon.maryland.gov
• Maryland Medicaid HCBS Waivers: https://health.maryland.gov/mmcp/waiverprograms/pages/home.aspx

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