Last updated 2026-07-25
TL;DR
An MDH assisted living license is issued by the Maryland Department of Health's Office of Health Care Quality under COMAR 10.07.14. Operators need a county use and occupancy determination, a level-of-care designation (Level 1, 2, or 3), a criminal background check, and an OHCQ inspection before opening. Processing generally takes several months, not weeks.
What is an MDH assisted living license, exactly?
In Maryland, any residence that offers housing plus personal care, health-related services, or supervision to adults who can't live fully independently needs an assisted living license from the Office of Health Care Quality (OHCQ), which operates inside the Maryland Department of Health (MDH). This applies whether you run a converted single-family home with four residents or a purpose-built facility with 80 units. The governing regulation is COMAR 10.07.14, Assisted Living Programs [1]. Maryland defines an assisted living program as "a residential or facility-based program that provides housing and food service and provides assistance with activities of daily living and health-related services to individuals who, because of their physical or mental disability, are unable to live independently" under Health-General Article §19-1801 [2]. That statutory definition is the one OHCQ inspectors and reviewers cite when they decide whether your business needs a license in the first place. A lot of new operators assume "assisted living" and "group home" are interchangeable in Maryland. They're not always the same regulatory category. Small group homes serving people with intellectual or developmental disabilities may fall under the Developmental Disabilities Administration instead of OHCQ's assisted living rules, depending on funding source and program design. If you're not sure which agency actually governs your model, that's the first phone call to make, before you sign a lease or start marketing beds.
What is assisted living, in plain terms?
Assisted living is a housing and care model for adults, usually older adults, who need help with daily tasks like bathing, dressing, medication reminders, or meal prep but don't need the round-the-clock skilled nursing you'd get in a nursing home. It sits between fully independent living and a nursing facility on the care spectrum. The federal government doesn't license assisted living directly. Every state runs its own system, with its own terminology, staffing ratios, and inspection cycle. That's why Maryland's rules under COMAR 10.07.14 look different from Florida's or Texas's licensing frameworks even though the day-to-day service (help with ADLs, medication management, meals, some supervision) looks similar on the surface. If you want a broader comparison across states before you commit to Maryland specifically, our state licensing guides page walks through how different states structure this. Maryland further breaks assisted living into three levels of care, and this matters a lot for staffing and licensing scope. Level 1 is for residents who are largely independent with occasional help. Level 2 covers residents needing moderate assistance and some nursing oversight. Level 3 is for residents with more significant medical or cognitive needs, including some who might otherwise need a nursing home placement. Each resident gets a level-of-care assessment, typically done by a licensed nurse using the state's approved assessment tool, before or shortly after admission [1].
What is a group home, and how is it different from assisted living?
A group home usually refers to a smaller residential setting, often serving people with intellectual/developmental disabilities, mental illness, or substance use recovery needs, rather than primarily serving older adults aging in place. The physical setup can look almost identical to a small assisted living home (a house, several bedrooms, shared common space) but the licensing authority and program requirements differ. In Maryland, group homes for people with developmental disabilities are typically licensed or certified through the Developmental Disabilities Administration (DDA), not OHCQ's assisted living program. Group homes tied to behavioral health services may fall under the Behavioral Health Administration. Assisted living programs licensed under COMAR 10.07.14 are specifically for adults needing personal care and health-related services, most commonly (though not exclusively) older adults [1][2]. If your business model is "small residential home, four to eight beds, personal care services for seniors," you're almost certainly looking at an OHCQ assisted living license. If it's "small residential home for adults with autism receiving state disability waiver funding," you're looking at DDA. Get this wrong early and you'll burn months redoing paperwork with the correct agency. For readers comparing the group home path more broadly against assisted living, see our group home vs assisted living comparison piece.
What is an assisted living facility supposed to provide?
An assisted living facility in Maryland is required to provide, at minimum, room and board, help with activities of daily living, medication management or assistance, and some level of health monitoring appropriate to the resident's assessed level of care. The exact scope depends on the resident's Level 1, 2, or 3 designation under COMAR 10.07.14 [1]. Beyond the basics, most facilities also handle housekeeping, laundry, three meals a day plus snacks, activities programming, and 24-hour staff availability, even if that staff isn't providing hands-on nursing care around the clock. A facility isn't required to have a registered nurse on-site 24/7 for Level 1 or Level 2 residents, but it does need a delegating nurse relationship for tasks like medication administration that go beyond simple reminders, consistent with Maryland's nurse delegation rules under the Board of Nursing. What assisted living does not provide, by design, is the intensive medical and skilled nursing care you'd get in a hospital or nursing facility. If a resident's needs progress beyond what the facility's license level allows, the facility is required to either get the resident reassessed and, if appropriate, transfer them to a higher level of care setting, or discharge them to a more appropriate placement. This is spelled out in Maryland's admission and retention criteria within COMAR 10.07.14 [1].
What is assisted living vs nursing home, really?
| Licensing authority | State health department (OHCQ) | State health department + CMS certification | |
|---|---|---|---|
| 24-hr RN on site | Not always required | Required under federal SNF rules [3] | |
| Typical resident need | Help with ADLs, some health monitoring | Skilled nursing, rehab, complex medical care | |
| Medicare coverage | Not covered for room and board | Covered for limited skilled stays post-hospitalization [4] | |
| Medicaid coverage | Sometimes, via HCBS waiver, varies by state | Yes, standard Medicaid nursing facility benefit | People often get surprised by that Medicare row. It matters enough that it deserves its own section below. |
The core difference is medical intensity and staffing. Nursing homes (called skilled nursing facilities federally) are licensed to provide 24-hour skilled nursing care, have a registered nurse on-site around the clock in most cases, and are subject to federal Medicare/Medicaid nursing home requirements under 42 CFR Part 483 [3]. Assisted living is a state-only licensing category, generally private-pay or covered through state Medicaid waiver programs rather than the standard Medicare nursing home benefit. | Feature | Assisted living (Maryland, COMAR 10.07.14) | Nursing home (skilled nursing facility) |
Does Medicare cover assisted living facilities?
No. Medicare does not cover the cost of room and board in an assisted living facility, and it generally doesn't cover the personal care services (help with bathing, dressing, meal prep) that make up the core of assisted living. Medicare.gov states plainly that Medicare "doesn't cover long-term care (also called custodial care)" if that's the only care a person needs [5]. Medicare will still pay for medically necessary services a resident receives while living in assisted living, things like doctor visits, physical therapy following an injury, or durable medical equipment, the same way it would for someone living at home. It just won't pay the facility's monthly rate for housing, meals, and personal care assistance. Medicaid is a different story, and this is where a lot of confusion comes from because the names sound similar. Some states, including Maryland through its Community Options waiver and other Home and Community-Based Services (HCBS) waivers, can help cover the cost of personal care services within an assisted living setting for financially eligible residents, even though Medicaid generally still doesn't cover the room and board portion [6]. Coverage rules, waiver waitlists, and eligibility income limits vary by state and change often, so confirm current waiver availability and income thresholds directly with your state Medicaid agency or Medicaid.gov's HCBS page [6] rather than relying on secondhand summaries, including this one.
How do I start a group home or assisted living business in Maryland?
Starting an assisted living business in Maryland (or a group home under a different licensing agency) generally follows a sequence: confirm the correct licensing agency, secure a compliant property, complete pre-licensing paperwork, pass inspection, then get your license issued. Skipping steps or doing them out of order is the single most common reason applications stall. Here's the realistic order of operations for the OHCQ assisted living path: 1. Confirm licensing category. Call OHCQ or check COMAR 10.07.14 to confirm your model fits assisted living rather than DDA or behavioral health group home licensing [1]. 2. Check local zoning. Contact your county planning or zoning office to confirm the property is zoned for a residential care use and get any required use and occupancy determination. This step alone can take weeks to months depending on the jurisdiction, and it's confirm-with-your-local-government territory, not something a state guide can promise in advance. 3. Secure the property. Whether you buy or lease, make sure the lease or deed doesn't conflict with the intended license type, and that the building can pass a life-safety and fire code inspection for the number of residents you plan to serve. 4. Submit the OHCQ license application. This includes organizational documents, floor plans, policy and procedure manuals, staffing plans, and background check clearances for the administrator and staff, per COMAR 10.07.14 application requirements [1]. 5. Pass pre-licensure inspection. OHCQ surveyors will inspect for life safety, physical plant compliance, staffing documentation, and policy readiness before issuing the license. 6. Get your license and start intake. Once issued, the license is typically tied to a specific location and bed capacity, not portable to a different address without a new review. Budget real time for this. Between zoning confirmation, property prep, and OHCQ review, most operators are looking at several months minimum from decision to opening day, not weeks. Anyone who tells you otherwise is guessing.
What does the OHCQ application actually require?
The application package for an assisted living license in Maryland typically includes a completed application form, disclosure of ownership and management, a staffing plan showing coverage for each shift, resident admission and retention policies, medication management procedures, an emergency preparedness plan, and fire marshal approval or documentation of a completed life-safety inspection [1]. You'll also need proof of the level of care you intend to offer (Level 1, 2, or 3), because that designation drives what staffing and nurse delegation arrangements are required. A Level 3 facility, serving residents with more significant needs, faces tighter staffing and health monitoring requirements than a Level 1 facility serving mostly independent residents. Background checks are non-negotiable. Administrators and direct care staff go through criminal history checks consistent with Maryland's requirements for health care facility employees, and any finding that disqualifies a candidate under state law will hold up licensure of that specific hire, even if the rest of the application is clean. Exact fee amounts, specific form numbers, and current processing timelines change periodically. Confirm current fee schedules and forms directly with the Office of Health Care Quality rather than relying on older published figures, since state agencies update these on their own schedule.
What should I expect during an OHCQ inspection?
OHCQ conducts both a pre-licensure survey before your license is issued and periodic unannounced inspections once you're operating, generally to check ongoing compliance with COMAR 10.07.14. Expect surveyors to review resident records, staffing schedules, medication administration records, incident reports, and the physical building itself for life-safety issues like clear exits, working smoke detectors, and proper storage of medications and hazardous materials. Surveyors will also interview staff and, where possible, residents, to check that the care being delivered on paper matches what's actually happening day to day. A beautiful policy manual won't save you if staff can't describe how they actually handle a fall or a medication error in real time. Common deficiency areas nationally, and Maryland is no exception, tend to cluster around medication management documentation, staff training records not being current, and incomplete resident care plans. Building your policy and procedure manual around the specific COMAR requirements, rather than a generic template, cuts down on these findings significantly. If you want a structured starting point instead of building every policy from scratch, our $299 State Group Home Licensing Kit includes Maryland-specific policy templates and a staffing plan framework built around COMAR-style requirements, which can save real time compared to drafting from zero. It's a starting template, not a substitute for reading COMAR 10.07.14 yourself or confirming current requirements with OHCQ.
What staffing does Maryland require for assisted living?
Staffing requirements under COMAR 10.07.14 scale with the level of care and the number of residents. A Level 1 facility with a handful of largely independent residents has lighter staffing obligations than a Level 3 facility housing residents with dementia or significant medical needs. At minimum, facilities need an administrator meeting state qualification requirements (which can include specific training hours or a professional license, depending on facility size and level), sufficient direct care staff to cover every shift, and a documented relationship with a delegating registered nurse for medication administration and health-related tasks that go beyond simple reminders. Staff training requirements typically cover topics like first aid, CPR, resident rights, infection control, and abuse/neglect reporting, with specific hour requirements set out in COMAR. Because these hour requirements and administrator qualification standards get updated periodically, confirm the current version directly against COMAR 10.07.14 or with OHCQ before finalizing your staffing plan, rather than working from an outdated summary.
How much does an MDH assisted living license cost, and how long does it take?
Exact license fees and renewal fees for Maryland assisted living programs are set by OHCQ and adjusted periodically, so treat any specific dollar figure you find online, including anything implied here, as something to verify directly with OHCQ's current fee schedule before you budget around it. What's more predictable is the timeline shape, even if exact weeks vary by county and caseload. Zoning confirmation can take anywhere from a few weeks to several months depending on your jurisdiction. Property buildout or renovation to meet life-safety code adds more time. The OHCQ application review and pre-licensure survey process adds more still. Stacking these realistically, most new operators are looking at a process measured in months, often six months or longer from the decision to pursue licensure to the day residents can move in, not the four-to-six-week timeline sometimes advertised by unrelated consulting services. Nobody should promise you a fast-tracked or automatic approval through OHCQ review, and no legitimate consultant can promise a specific approval date. State health department reviewers work through applications in the order they're complete and correctly filed, and an incomplete package goes to the back of that line.
Frequently asked questions
What is assisted living?
Assisted living is a residential care model for adults who need help with daily activities like bathing, dressing, and medication management but don't need the round-the-clock skilled nursing of a nursing home. States license and regulate it individually; Maryland does so through OHCQ under COMAR 10.07.14.
What is a group home?
A group home is a small residential setting, often for people with intellectual/developmental disabilities, mental illness, or in recovery, providing housing and support services. In Maryland, group homes are typically licensed by the Developmental Disabilities Administration or Behavioral Health Administration rather than OHCQ, depending on the population served.
What is an assisted living facility?
An assisted living facility is a licensed residence that provides housing, meals, and help with daily activities plus some health-related services to adults who can't fully live independently. In Maryland it's licensed under COMAR 10.07.14 and assigned a Level 1, 2, or 3 designation based on resident acuity.
What is assisted living vs nursing home?
Assisted living provides housing plus help with daily activities and light health monitoring, while a nursing home provides 24-hour skilled nursing care for residents with more intensive medical needs. Nursing homes must meet federal skilled nursing facility rules under 42 CFR Part 483; assisted living is regulated at the state level only.
What does assisted living provide?
At minimum: housing, meals, help with activities of daily living (bathing, dressing, toileting), medication management or reminders, housekeeping, and some level of health monitoring matched to the resident's assessed care level. It does not provide the intensive skilled nursing services a nursing home does.
How do I start a group home?
Confirm which state agency licenses your specific population (seniors, IDD, mental health, recovery), check local zoning for the property, complete the agency's application with policies, staffing plans, and background checks, then pass a pre-licensure inspection. The correct starting agency varies by state and population served.
What's the difference between assisted living and nursing home care?
Assisted living residents are generally more independent and need help rather than hands-on medical care; nursing home residents typically need daily skilled nursing or rehabilitation. Staffing, licensing authority, and Medicare/Medicaid coverage rules differ significantly between the two categories.
Does Medicare cover assisted living facilities?
No. Medicare does not cover room, board, or personal care costs in assisted living. Medicare.gov confirms it doesn't cover custodial long-term care when that's the only service needed, though it will still cover medically necessary services like doctor visits or therapy a resident receives while living there.
How do I start a group home application in my state?
Start by identifying the specific state agency that licenses your population (aging services, developmental disabilities, behavioral health, or health department for assisted living), then request their current application checklist directly, since forms and fees change and vary by state.
Does Medicaid pay for assisted living in Maryland?
Medicaid can help cover personal care services in some Maryland assisted living settings through Home and Community-Based Services waivers like the Community Options waiver, for financially eligible residents, but it generally doesn't cover room and board. Confirm current eligibility and waitlist status with Maryland Medicaid directly.
What is the MDH assisted living license called officially?
Maryland licenses these programs as "assisted living programs" through the Office of Health Care Quality (OHCQ) under COMAR 10.07.14, within the Maryland Department of Health. There isn't a separate document called an "MDH license"; OHCQ is the issuing office within MDH.
How long does it take to get an assisted living license in Maryland?
There's no fixed timeline and no agency guarantees a specific approval date. Realistically, factoring in zoning confirmation, property preparation, application review, and pre-licensure inspection, most operators should expect a process lasting several months to over half a year, not weeks.
Sources
- Maryland Division of State Documents, COMAR 10.07.14 Assisted Living Programs: Maryland's assisted living licensing regulation, level of care categories, and application/staffing requirements
- Maryland General Assembly, Health-General Article §19-1801: Statutory definition of an assisted living program in Maryland
- Code of Federal Regulations, 42 CFR Part 483: Federal requirements for skilled nursing facilities, including 24-hour nursing standards
- Medicare.gov, Skilled Nursing Facility Care: Medicare coverage for limited skilled nursing facility stays following hospitalization
- Medicare.gov, Long-Term Care: Medicare does not cover custodial long-term care or assisted living room and board
- Medicaid.gov, Home & Community Based Services: Medicaid HCBS waivers can cover personal care services in community settings, subject to state variation and eligibility