Maryland home health agency license: the CON gate, OHCQ licensing and Medicare

Home health agency or residential service agency?

Maryland draws the line by the mix of services you offer, not by whether you employ nurses. Under Health-General §19-401, a home health agency provides, directly or by contract, skilled nursing, home health aide services, and at least one other home health care service, all centrally administered, to sick or disabled people in their homes.⁠⁴ The other services that count are audiology and speech pathology, dietary and nutritional services, drug services, laboratory, medical social services, occupational therapy, physical therapy, and medically necessary sickroom equipment and supplies.⁠⁴ To qualify for a license, the agency must provide skilled nursing, home health aide services and at least one other service approved by the Secretary, and it must meet the certificate of need requirements of Subtitle 1.⁠⁶

An agency that provides less than that full mix is licensed as a residential service agency (RSA), not a home health agency. OHCQ’s RSA application repeats the three-part definition so applicants can tell which license applies.⁠¹² MHCC describes the RSA as the home care license for agencies offering no more than two types of home care service, and says no CON is needed for one.⁠⁸ RSAs can employ RNs and send nurses into homes. What an RSA cannot do is offer the full home health package, and in practice it is not the license used for Medicare home health billing. MHCC’s own comparison table describes RSAs as usually private pay or Medicaid and not Medicare-certified.⁠¹¹ For the RSA route, see the Maryland residential service agency guide.

One more boundary matters:

• Hospice. If your home health agency runs a hospice program that is distinct from its other services, you also need a hospice care program license.⁠⁴ MHCC’s May 2026 schedule says it is not accepting hospice CON applications either.⁠¹⁰

The certificate of need comes first

OHCQ’s licensing page says it plainly: to become eligible for a home health license, you must first apply for a CON from MHCC.⁠¹ OHCQ’s application adds that, under Health-General §19-114(b), you need a CON or an MHCC exemption before you may apply at all. The first required attachment is MHCC documentation that you have one or the other.⁠²

MHCC’s CON process for home health has these stages:⁠⁸

1. Letter of intent

   It can be filed only on the dates in a published review schedule.⁠¹⁰

2. Pre-application conference

   with MHCC staff. The schedule also encourages applicants to talk to staff before they file a letter of intent.⁠¹⁰

3. CON application and completeness review

   MHCC staff send rounds of completeness questions.

4. Docketing and formal review

   This includes public comment and, if more applicants qualify than the county can absorb, a comparative review.

5. Staff report and Commission decision

   The Commission approves, approves with conditions, or denies.

6. First use approval

   After approval you must meet the conditions and get MHCC’s first use approval before you start serving patients.

For a sense of the clock: the first staff report from the 2025 cycle, covering the Western Maryland region, shows an application filed February 8, 2026, completeness questions on April 2 and May 15, 2026, docketing on June 23, 2026, and a staff recommendation dated September 17, 2026.⁠¹¹ That is about seven months from filing to staff recommendation for an uncontested application, before the Commission votes or OHCQ licensing starts.

Who MHCC will accept an application from

This is the rule that rules out most first-time founders. The State Health Plan chapter for home health services (COMAR 10.24.16, effective April 11, 2016) lets only three types of applicant apply:⁠⁹

• an existing Medicare-certified home health agency licensed in Maryland that wants to add jurisdictions;
• an existing Medicare-certified home health agency licensed in another state that wants to establish a new agency in Maryland; or
• a licensed and accredited hospital or nursing home, or a Maryland RSA providing skilled nursing services, in good standing, that wants to establish a new home health agency.

Every applicant must also meet the general qualifications in COMAR 10.24.16.06C:⁠⁹

• no suspension of Medicare or Medicaid payments in the last 5 years
• no Medicare or Medicaid fraud or abuse conviction in the last 10 years
• at least satisfactory findings, with no serious adverse citations, on the two most recent survey cycles
• accreditation through a state-recognized deeming authority for at least the three most recent years
• an accepted plan of correction for any valid, serious patient-related complaint in the past three years
• compliance with federal and state quality reporting
• enough money to carry out the project on MHCC’s performance timetable
• a record of serving all payer types, including Medicare, Medicaid, private insurance, HMOs and self-pay
• a sworn statement that no owner or senior manager, including those of any related entity, has been convicted of a felony or crime, or received a plea or diversionary disposition for one, in the last 10 years

For an RSA applicant, the plan requires an established quality assurance program that collects process, outcome and experience-of-care measures, plus accreditation through a deeming authority recognized by the Maryland Department of Health for at least the three most recent years.⁠⁹ MHCC’s 2025 guidance also required the RSA to have operated and provided skilled nursing for at least three years.⁠¹¹ The Western Maryland applicant that staff recommended for approval in September 2026 was an RSA licensed since 2009 and fully accredited since 2018.⁠¹¹

What this means if you are starting from zero: the only realistic route into Maryland home health is to open a skilled-nursing RSA, get accredited, build three years of quality data and a mixed payer base, and then apply in a future review cycle for a county MHCC has found to have a need. The other routes are buying an existing agency or coming in as an established out-of-state Medicare agency (both covered below).

Where and when MHCC finds a need

MHCC opens a county for new home health agencies only when the county meets one of three tests:⁠⁹

A county is not found to have a need if it has an agency with less than three years of operation, or a newly authorized agency that has not yet opened.⁠⁹ MHCC may group neighboring counties into a region, but it will not combine a county of 300,000 or more people with others.⁠⁹ No new specialty home health agencies will be established.⁠⁹ MHCC also caps new entrants per review cycle. In a county or region with four or more existing agencies, it may approve new agencies up to 40% of the existing number. Where there are fewer than four, it may approve one.⁠⁹

The 2025-2026 cycle. MHCC published the review schedule in the Maryland Register on July 11, 2025. The Commission approved that cycle’s quality measures and performance levels on June 12, 2025.⁠¹¹ No county qualified under insufficient choice.⁠¹¹ These counties qualified:⁠¹¹

• Highly concentrated market: Allegany, Calvert, Caroline, Cecil, Charles, Dorchester, Garrett, Kent, Queen Anne’s, St. Mary’s, Somerset, Talbot, Washington, Wicomico and Worcester.
• Insufficient choice of quality agencies: Anne Arundel, Baltimore County, Carroll, Charles, Frederick, Garrett, Harford, Howard, Montgomery, Prince George’s, St. Mary’s, Wicomico and Baltimore City.

Status as of October 12, 2026. MHCC’s CON review schedule, posted in May 2026, says the statewide home health review “is ongoing” and that “the Commission is not accepting any additional CON applications for Home Health Agency projects at this time.”⁠¹⁰ The schedule also says letters of intent for scheduled reviews can be received only according to published schedules.⁠¹⁰ A future cycle needs a new schedule and new need findings. Under the three-year rule above, counties where 2025-cycle agencies are approved but not yet open will drop out of need for a while.⁠⁹ MHCC’s pages and schedule do not say when the next home health review schedule will be published or which counties will qualify. Before planning around a county, ask MHCC’s Chief of Facilities (410-764-3337, listed on the schedule) whether a new schedule is expected.⁠¹⁰

What MHCC reviews in a CON application

Once an application is accepted, it is measured against the review standards in COMAR 10.24.16.08:⁠⁹

• Medicare and Medicaid are mandatory. You must be, or agree to become, licensed and Medicare- and Medicaid-certified, and accept clients whose main payer is either program. A private-pay-only home health agency cannot get a CON.
• Charity care with a number attached. You need a written charity care policy. The agency must give a client a probable-eligibility decision within two business days of a request. You need annual public notice, notices posted in your office and on your website, and a sliding fee scale with time-payment plans. You must commit to at least the average charity care that home health agencies provided in the county or region in the latest year of data, and show a specific plan for reaching it.
• Fees and payment plans. Tell clients your fees at assessment, before care starts, and give MHCC and each client a written time-payment policy.
• Financial feasibility. Projections of visits, revenue, staffing and expenses must be consistent with the recent experience of Maryland agencies serving each county you propose.
• Impact on existing agencies. Show how your agency would affect existing agencies’ caseloads, staffing and payer mix.
• Solvency. Show you can meet the capital reserve and other solvency requirements CMS sets for Medicare-certified agencies.
• Linkages. Document ties with hospitals, nursing homes, continuing care retirement communities, hospices, assisted living providers, Adult Evaluation and Review Services, adult day care programs, the local Department of Social Services and home-delivered meal programs. A new agency provides this when it requests first use approval.
• Discharge planning and data. Have a formal discharge planning process, and be able to report to MHCC’s annual home health survey, CMS’s OASIS and HHCAHPS.

In a comparative review, MHCC breaks ties using these preferences, in order: higher quality performance, maintained or improved performance over three years, a broader record of serving all payer types and low-income people, and a broader range of services.⁠⁹

Approvals come with conditions. In the September 2026 Western Maryland report, staff recommended these conditions, among others:⁠¹¹

• post charity care and sliding-fee policies online before first use
• document community linkages before first use
• notify MHCC within 30 days if, in the first three years after Medicare certification, the agency’s CMS overall rating averages below three stars or it receives a condition-level or immediate jeopardy citation
• file annual reports on referrals, admissions and denials by payer, region and age

Buying an existing agency instead

A change of ownership of a home health agency does not need a CON. You file a Notice of Acquisition with MHCC that includes organizational charts before and after the deal, ownership tables and a description of the transaction. MHCC advises filing at least 60 days ahead. Indirect or upstream ownership changes also need notice.⁠⁸ The State Health Plan adds these rules:⁠⁹

• You must buy the whole agency. Authority to serve a county cannot be sold separately.
• Buying a freestanding agency gives you all of its authorized jurisdictions. Buying a hospital-based agency gives you only the parent hospital’s jurisdiction, unless the agency had won wider authority.
• You must commit to serve Medicare, Medicaid, commercial, self-pay and uninsured clients, and to provide charity and reduced-charge care.
• You take on any ongoing CON conditions.
• You must disclose your corporate structure, purchase price and source of funds.
• If you will not keep the seller’s Medicare provider agreement, you need a plan to operate until you obtain Medicare certification within 18 months.
• No owner or principal may have a felony conviction or plea within 10 years.

Under the federal rule described in the Medicare section below, buying an agency that has been enrolled in Medicare for less than 36 months can trigger new enrollment. That is blocked while the federal freeze lasts.⁠¹³

The OHCQ license application

With MHCC documentation in hand, you apply to OHCQ’s home health program. The application must be typed, because handwritten applications are returned, and you submit it through the “Submit a License Application” link on OHCQ’s website. There is no fee to apply.⁠² The form asks for:

• the patient populations you will serve (adult, pediatric, maternal and child health, psychiatric)
• each service, and whether it is provided directly, by contract or both, with contractor names
• every county you will serve
• whether you want your accrediting organization or OHCQ to do the initial federal certification survey⁠²

You must list every owner, member, partner or investor holding 2% or more, directly or indirectly. Corporations also list their director and officers.⁠²⁠³ The disclosure section asks about OHCQ-licensed facilities you now own or operate or used to, any license revoked, suspended or denied by the Maryland Department of Health, any criminal conviction involving Medicare, Medicaid or other Social Security Act Title 18, 19 or 20 programs, and any felony conviction of anyone with an ownership interest.⁠² You sign under penalty of perjury.

Required attachments:⁠²

1. MHCC documentation of your CON or exemption (COMAR 10.24.01).
2. Names of your Professional Advisory Group members.
3. The Civil Rights Information Request.
4. Proof of accreditation (award letter and most recent full survey report), or proof that you have applied for it.
5. Written notice if an accrediting organization will do your initial federal certification survey.
6. Your written procedures required by COMAR 10.07.10.04, cited by document and page number. These are your drug and biologicals procedures and your hours-and-on-call procedures (both described below).
7. The declaration page of your general liability insurance.
8. A letter of good standing from the State Department of Assessments and Taxation, ordered through SDAT Business Express.
9. Your workers’ compensation declaration page. Corporations and LLCs not required to carry coverage submit a Certificate of Compliance. Sole proprietors and partnerships with no employees submit a Letter of Exemption.

OHCQ holds an incomplete application for 180 days from the date it first receives it, then closes it, and you would have to start over.⁠² An agency whose parent is outside Maryland can be licensed if it has at least one Maryland branch, or if the parent is in a bordering state that has a reciprocal agreement or the agency agrees to OHCQ inspection.⁠²⁠³

Survey, decision and provisional licenses

Once OHCQ approves the paperwork, it schedules an on-site licensure survey: a tour of the agency, staff interviews and a records review.⁠² If there are no deficiencies, you receive a Notice of Compliance and the license. If there are deficiencies, you receive a Statement of Deficiencies and have 10 business days to submit a plan of correction. The license issues once OHCQ accepts the plan.⁠²

OHCQ may instead issue a provisional license for less than a year. This can happen if you have not shown substantial compliance but have agreed in writing to correct the problems. A provisional license cannot be renewed unless the deficiencies are substantially corrected, and it cannot run more than 2 consecutive years.⁠³ Denial comes with a letter giving the reasons and your appeal rights.⁠²

Leadership and governance OHCQ will check

Administrator. The administrator must be a physician, an RN, or a college graduate with a bachelor’s or higher degree in a health-related field. They also need at least 1 year of supervisory experience in hospital management, home health management or public health program management.⁠³⁠⁵ The governing body appoints the administrator, who is responsible for overall management and finances.⁠³

Service director and nursing supervisor. The administrator appoints a full-time service director (a physician, an RN, or another professional qualified by advanced training) who is available at all times during operating hours.⁠³ Nursing must be supervised by an RN with 2 to 3 years of experience or education in community health nursing.⁠³

Professional Advisory Group. The group must include a licensed physician, an RN, a representative of each allied discipline you use, and a consumer representative. The consumer must live in your service area and have no financial or professional interest in the agency.⁠³ It reviews your policies on scope of services, admission and discharge criteria, medical supervision, emergency care, records and referrals. It must meet at least three times each calendar year with minutes, and the governing body must document what it did with each recommendation.⁠³

By-laws and contracts. The governing body adopts written by-laws and reviews them every year. Every service you do not provide directly needs a written contract, reviewed at least annually. The contract must state that only the parent agency bills and collects co-insurance, and that only the parent agency accepts patients.⁠³

Insurance. You must carry liability insurance covering all employees and make sure contractors have their own liability coverage.⁠³

Operating rules written into the license

These requirements come from Health-General §19-404 and COMAR 10.07.10, and OHCQ checks them at survey:⁠³⁠⁵

• Physician orders. You accept a patient for skilled care only on a physician’s signed order obtained within 28 days after acceptance. You must try to reach the physician no later than 10 days after acceptance and record each attempt.
• Hours and on-call. Services must be available at least 8 hours a day, 5 days a week, with emergency coverage 24 hours a day, 7 days a week. Whoever answers patient calls must be able to reach an RN immediately, and no later than half an hour after the call. That RN assesses the patient and gives or arranges emergency care.
• Start of care. When a physician’s order calls for it, service begins within 24 hours of the referral.
• Drugs and treatments. Your written procedures must cover IV therapy, chemotherapy, parenteral feeding and injections, and 24-hour availability while IV medications or nutrition are running. Only physicians and RNs may administer drugs, or LPNs under RN supervision following the physician’s plan and an RN’s care plan. The procedures must also cover medication error documentation and disposal of controlled drugs.
• Clinical records. Progress notes are due within 5 working days of the visit. Discharge records must be complete within 30 days of discharge. Records are kept at least 5 years after discharge.
• Utilization review. A committee reviews records at least quarterly, sampling 10% of the unduplicated annual caseload or 40 records, whichever is less. Every active record is reviewed at least every 60 days.
• Statistics. You keep county-by-county statistics on patients, visits by discipline, diagnoses, referral sources, discharge reasons and payers. You prepare an annual report within 90 days after your fiscal year ends and submit it with each renewal.
• Patient rights and complaints. Patients receive a written statement of rights, including your uncompensated care policy and itemized bills on request. Filing a complaint must not disrupt service, and complaint summaries go to the Professional Advisory Group and to OHCQ at least annually.
• Discharges. OHCQ issued a transmittal on discharge planning requirements and reporting on March 24, 2026, and posted a discharge requirements in-service dated May 8, 2026.⁠¹

Staff qualifications and training

All professional staff must be licensed or otherwise authorized under Maryland law.⁠³ A home health aide must have at least 1 year of practical experience in a hospital, nursing home or home care program, or have completed the Maryland Red Cross Home Care Course or an equivalent program, and works under professional supervision.⁠³

Aides receive a structured training and orientation program covering 13 listed topics, including personal care and activities of daily living, nutrition and special diets, aging, infection-free and safe home environments, when to refer changes to the nurse supervisor, and confidentiality.⁠³ Aides are supervised on site periodically, with documentation. All professionals and aides attend in-service education every quarter, with topics and attendance documented for surveyors.⁠³

Each personnel file holds:⁠³

• proof of licensure or certification
• qualifications for the job
• periodic performance evaluations
• a tuberculosis certification, only for staff who will directly care for TB patients or who are immigrants from Africa, Asia or Latin America

COMAR 10.07.10 sets out the TB screening methods and requires certification within 10 days after the person starts work. Every employee and volunteer must be taught the signs and symptoms of active TB.⁠³

Medicare enrollment and the 2026 freeze

Medicare is not optional for a CON-approved Maryland agency, because MHCC makes Medicare and Medicaid certification a review standard and a typical approval condition.⁠⁹⁠¹¹ On May 13, 2026, CMS stopped enrolling new home health agencies, branches and practice locations in Medicare nationwide. Only applications that a Medicare contractor received before that date are still being processed.⁠¹³ CMS’s memo to the states adds these rules:⁠¹⁴

• applications filed during the moratorium are denied and must be filed again after it ends
• there are no exceptions for individual providers
• accreditation does not produce deemed status for a new agency while the moratorium lasts

The moratorium runs six months and may be extended in six-month increments.⁠¹⁵ CMS’s moratoria page, last updated August 27, 2026, still described the six-month period with no extension, so the first period ends about mid-November 2026 unless CMS extends or lifts it.⁠¹⁵ Agencies that enroll within 6 months after it lifts are put in the “high” screening level. An agency that has a non-exempt change in majority ownership within 36 months of its first enrollment must enroll again as a new agency, which the moratorium blocks.⁠¹³

MHCC’s September 2026 staff report shows what this means in practice. The applicant had planned to be licensed in month six and Medicare-certified in month nine after CON approval. The project is now on hold, OHCQ continues to process licensure, and Medicare certification waits until the moratorium ends.⁠¹¹ CMS left Medicaid home health moratoria to each state.⁠¹³ The sources reviewed show no Maryland Medicaid enrollment hold on home health agencies, but the Maryland Department of Health has used its own moratoria for other provider types, so ask the Medicaid program whether one applies before you file.

Renewal, inspections and changes

The license is valid for 1 year from issuance and cannot be transferred. It becomes void if the agency stops operating.⁠³ File for renewal at least 60 days before the license expires.⁠³ Post the license in your office and in each branch. Each branch also displays a Department statement of its authority to operate under the parent agency.⁠³ To give up the license voluntarily, you must notify patients, their physicians and payers at least 30 days in advance.⁠³

On inspection frequency, the rules disagree. Health-General §19-407 and COMAR 10.07.10.05 require a survey at least every 3 years, while COMAR 10.07.10.04E says inspections at least annually, with a written report within 30 days.⁠³⁠⁷ The sources do not say how often OHCQ actually surveys agencies in practice, so ask the Home Health Agency Team which interval it applies. OHCQ also investigates complaints, and agencies must be open for inspection during business hours.⁠¹⁠³

Licensed agencies use OHCQ forms to change the agency name, address, services or counties served.⁠¹ Adding a county is not just paperwork with OHCQ: MHCC treats expansion into a jurisdiction you are not authorized to serve as a CON project, subject to the same need and quality rules.⁠⁹ MHCC also runs an annual home health survey, conducted around the fourth quarter each year, and the State Health Plan expects applicants to take part in it.⁠⁸⁠⁹

OHCQ’s Home Health Agency Team: (410) 402-8040. MHCC CON questions: 410-764-3460.⁠¹

Sources

1. 1
   Maryland Department of Health, Office of Health Care Quality, Home Health Agencies Checked 12 Oct 2026 · Back to text ↑
2. 2
   Maryland Department of Health, Office of Health Care Quality, Application for a Home Health Agency License (03.18.2026) Checked 12 Oct 2026 · Back to text ↑
3. 3
   Maryland Division of State Documents, COMAR 10.07.10, Home Health Agencies Checked 12 Oct 2026 · Back to text ↑
4. 4
   Maryland General Assembly, Health-General §19-401, Definitions Checked 12 Oct 2026 · Back to text ↑
5. 5
   Maryland General Assembly, Health-General §19-404, Rules and regulations Checked 12 Oct 2026 · Back to text ↑
6. 6
   Maryland General Assembly, Health-General §19-406, Qualifications for license Checked 12 Oct 2026 · Back to text ↑
7. 7
   Maryland General Assembly, Health-General §19-407, Inspections Checked 12 Oct 2026 · Back to text ↑
8. 8
   Maryland Health Care Commission, Home Health Checked 12 Oct 2026 · Back to text ↑
9. 9
   Maryland Health Care Commission, State Health Plan for Facilities and Services: Home Health Agency Services (COMAR 10.24.16, incorporated by reference) Checked 12 Oct 2026 · Back to text ↑
10. 10
    Maryland Health Care Commission, Schedules for Certificate of Need Review (posted May 2026) Checked 12 Oct 2026 · Back to text ↑
11. 11
    Maryland Health Care Commission, Staff Report and Recommendation, Home Health Agency CON, Western Maryland Region (September 17, 2026) Checked 12 Oct 2026 · Back to text ↑
12. 12
    Maryland Department of Health, Office of Health Care Quality, Application for a Residential Service Agency License (06.26.2026) Checked 12 Oct 2026 · Back to text ↑
13. 13
    Federal Register (Centers for Medicare & Medicaid Services), Announcement of Nationwide Temporary Moratorium on the Enrollment of New Home Health Agencies (May 15, 2026) Checked 12 Oct 2026 · Back to text ↑
14. 14
    Centers for Medicare & Medicaid Services, QSO-26-11-HHA/Hospice, enrollment moratorium Checked 12 Oct 2026 · Back to text ↑
15. 15
    Centers for Medicare & Medicaid Services, Provider Enrollment Moratoria Checked 12 Oct 2026 · Back to text ↑

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