How to start a home care agency in Maryland and reach your first client faster
Maryland licenses personal care, and the license leans clinical. The Residential Service Agency license from OHCQ expects a registered nurse to assess clients and supervise care, certified caregivers for clients the nurse says need one, written policies on every COMAR 10.07.05 topic and a business plan. Medicaid personal assistance then needs enrollment in the new MPRIME portal and LTSSMaryland timekeeping, and home health and hospice need a Certificate of Need first. We put all of it in the right order for you.
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- You own 100%. No franchise fees or royalties
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- Christine OchimasRN, LMFT, MBA
- All three care typesNonmedical, home health, hospice
- Written to Maryland rulesCOMAR 10.07.05 and COMAR 10.09.84
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Updated November 2026 · Reviewed by Christine Ochimas, RN, LMFT, MBA
Answer two questions. See exactly what Maryland requires.
Personal assistance for Community First Choice participants
- State license
- RSA license from OHCQ (COMAR 10.07.05); Medicaid conditions in COMAR 10.09.84.06
- Who you deal with
- OHCQ and the Maryland Department of Health Medicaid Administration
- Must haves
- RSA license, Maryland Medicaid enrollment in MPRIME (Provider Type 76), an employed registered nurse, CNAs or CMTs for delegated nursing tasks, State criminal history checks on all direct service workers, LTSSMaryland EVV
- Realistic time to first client
- Several months
Orientation for Maryland only. We confirm your exact path on the free call.
Three places new Maryland agencies lose months
Each one keeps you paying rent, insurance and payroll while no clients arrive.
A nurse led license, not a business permit
COMAR 10.07.05 requires a registered nurse to assess each new client who needs skilled services and help with daily activities, decide whether a certified nursing assistant is needed, and visit on site at least every 45 days to 4 months depending on medications. Clients who need a certified caregiver for daily activities or medication administration must get one. Owners who budgeted for companions find out late.
What it costs: RN payroll and certified caregiver wages that were never in the business plan, and clients you cannot accept until they are.
The application that sits for 180 days
OHCQ accepts only a typed application with a business plan, an organizational chart, policies for every topic in COMAR 10.07.05.08B, an SDAT good standing letter and proof of workers' compensation, plus the online RSA Certification on worker classification. OHCQ holds an incomplete application for 180 days, then closes it.
What it costs: Months of rent and insurance with no license, and a new application from scratch if yours is closed.
Medicaid enrollment moved to a new portal
Maryland Medicaid replaced ePREP with MPRIME on October 13, 2026, after holding new enrollment applications from July and August 2026. Drafts and documents in ePREP did not carry over. After enrollment, every personal assistance worker must clock in and out through LTSSMaryland EVV before the agency can bill.
What it costs: Weeks with licensed staff and Community First Choice clients you cannot bill for.
What does a delay cost your agency?
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Home care vs home health vs hospice in Maryland
The three sound alike and are regulated differently. The one you choose decides your regulator, staffing, startup capital and timeline.
| Topic | Nonmedical home care | Home health (skilled) | Hospice |
|---|---|---|---|
| What your staff do | Personal care and home health aide services (RSA license); housekeeping, meals, shopping and errands only (no license) | Skilled nursing, home health aide services and at least one other home health care service, centrally administered | Palliative and supportive care for people who are terminally ill and their families; general (skilled) or limited (nonskilled) programs |
| State license | OHCQ Residential Service Agency license (COMAR 10.07.05), valid 3 years | OHCQ home health agency license (COMAR 10.07.10), valid 1 year | OHCQ hospice care program license (COMAR 10.07.21), valid 3 years |
| Certificate of Need | No | Yes: MHCC Certificate of Need or exemption before licensure | Yes for a general hospice: MHCC Certificate of Need before licensure |
| Main payers | Private pay; Medicaid personal assistance through Community First Choice, CPAS and the Home and Community-Based Options Waiver, paid by Maryland Medicaid directly | Medicare, HealthChoice MCOs, commercial insurance | Medicare hospice benefit, HealthChoice MCOs |
| Medicare | Not covered | Accreditation or state survey, then Medicare enrollment; check the CMS moratorium | Accreditation or state survey, then Medicare enrollment; check the CMS moratorium |
| Key staff | Registered nurse for assessments, delegation and supervision; CNAs or CMTs where the nurse requires them | Qualified administrator, professional advisory group, registered nurse reachable within 30 minutes around the clock, trained home health aides | Medical director, registered nurses, interdisciplinary team |
| Startup capital | Moderate: RN time and certified caregiver wages from the start | Higher: Certificate of Need, clinical payroll before Medicare revenue | Highest: Certificate of Need, interdisciplinary team before revenue |
| Time to first client | Months (private pay) to several months (Community First Choice) | Longest: Certificate of Need, licensure, survey, enrollment | Longest: Certificate of Need, licensure, survey, enrollment |
Most Maryland owners start as a Residential Service Agency. The RSA license covers personal care, nursing and therapy in the home, but an RSA may not advertise itself as a home health agency or hospice unless it holds that separate license (COMAR 10.07.05.06). Home health and general hospice both start with a Certificate of Need from MHCC, filed on the Commission's published review schedule. We plan both from day one so your policies, nurse and hiring grow with you.
Maryland requirements at a glance
| Home care license | Residential Service Agency (RSA) license from the Maryland Department of Health, Office of Health Care Quality (OHCQ), under COMAR 10.07.05. Valid 3 years and lists each home health care service you provide. |
|---|---|
| When no license is needed | Agencies that provide only household and family support services: light housekeeping, meal planning and preparation, shopping and errands, and child care for children with no medical needs (COMAR 10.07.05.03B) |
| Home health and hospice | Licensed by OHCQ under COMAR 10.07.10 (home health) and COMAR 10.07.21 (hospice), after a Certificate of Need from the Maryland Health Care Commission (MHCC) |
| Medicaid home care programs | Community First Choice (COMAR 10.09.84), Community Personal Assistance Services and the Home and Community-Based Options Waiver, run by the Maryland Department of Health Medicaid Administration and paid fee for service |
| Medicaid enrollment | MPRIME portal since October 13, 2026 (it replaced ePREP). Personal assistance agencies enroll as Provider Type 76. |
| Caregiver staffing | Registered nurse assessment and supervision; a certified caregiver (CNA or certified medication technician) for clients who need one for daily activities or medication administration |
| Background checks | State criminal history records check or private agency background check before work starts (Health-General §19-1902); Community First Choice requires a State check on all direct service workers, nurses included |
| Electronic visit verification | LTSSMaryland EVV (the ISAS system) by mobile app, phone or one time password device for Community First Choice, Community Options, CPAS and ICS personal assistance |
| Medicare (home health, hospice) | Accreditation by a CMS approved organization or a state survey, then Medicare enrollment. New enrollment has been paused nationwide since May 13, 2026. |
| Entity filing | State Department of Assessments and Taxation (SDAT) through Maryland Business Express; OHCQ and Maryland Medicaid both require good standing |
Summary of Maryland requirements as of November 2026. Rules change; confirm with each agency before filing.
Step by step: launching a home care agency in Maryland
The order matters. Your nurse, policies and SDAT good standing must be in place before the OHCQ application, because OHCQ holds incomplete applications for 180 days and then closes them. Medicaid enrollment and EVV come after the license.
Form the business with SDAT
File your LLC or corporation through Maryland Business Express, get an EIN, register for withholding with the Comptroller and for unemployment insurance in BEACON, and register for the FAMLI program. Order the SDAT good standing letter you will attach to the OHCQ application.
You do this; we give you the checklistDecide your services and payer mix
Household support only needs no license. Personal care, home health aide services, nursing or therapy need the RSA license, and the application asks you to list each service. Decide on private pay, Community First Choice or both. Use the path finder above.
Decided on your free consultationSet up insurance and employment basics
Buy workers' compensation (OHCQ asks for the declaration page), plus general and professional liability and auto coverage. Build Maryland earned sick and safe leave into payroll: one hour for every 30 hours worked, paid if you have 15 or more employees. FAMLI contributions start January 1, 2027.
You do this; we specify what is requiredHire your nurse and write the policies
Bring on the registered nurse who will assess clients, write plans of care and supervise. Write policies for every COMAR 10.07.05.08B topic: administration, personnel, patient care, informed consent, and environment and safety. Add a business plan with a one year budget, a marketing plan and a detailed service description, plus an organizational chart.
We write this for youBuild the caregiver pipeline
Screen every caregiver before referral: criminal history or private background check, license or certificate check with the Board of Nursing, TB screening, references, work history, I-9, an in person interview and a skills demonstration. Train on the COMAR 10.07.05.11 topics, including CPR and infection control. Outside trainers need OHCQ approval.
We set up the system and trackerApply to OHCQ for the RSA license
Submit the typed application and attachments through OHCQ's online license application link, and have someone with authority over pay practices complete the online RSA Certification on worker classification. OHCQ may inspect before deciding and can charge $250 for each extra prelicensure visit.
We prepare the applicationEnroll in Maryland Medicaid
Apply in MPRIME as a personal assistance provider (Provider Type 76). MPRIME checks your SDAT good standing, and each location needs its own NPI and a current W-9. Maryland Medicaid says limited risk applications average 2 to 3 weeks and moderate and high risk applications 4 to 6 weeks, because of site visits.
We prepare and manage itSet up LTSSMaryland and EVV
Register your agency account in the LTSSMaryland Provider Portal and train every worker to clock in and out with the EVV mobile app or by phone. Collect participant signatures at least monthly and report incidents within 24 hours, as COMAR 10.09.84 requires.
We walk you through setup
Certified caregivers, nurse supervision and background checks
Maryland's RSA rules tie caregiver qualifications to what each client needs, as judged by a registered nurse. COMAR 10.07.05.10 to .12 set the screening, training and supervision rules, and the Maryland Board of Nursing certifies nursing assistants and medication technicians.
- Nurse assessment: A registered nurse assesses each new client who needs skilled services and help with daily activities, helps write the plan of care, and decides whether a certified nursing assistant is required. Assessments are repeated at least once a year and after a significant change in condition.
- Nurse supervision visits: On site at least every 45 days if staff give medications, every 3 months if they help clients take their own medications, and every 4 months otherwise, or more often if the nurse decides.
- Certified caregivers: An agency must send a CNA or certified medication technician to a client who needs one for daily activities or medication administration. An uncertified worker is allowed only for clients who need no help with daily activities, when the nurse finds no predictable adverse health consequences, or when a capable adult client signs a waiver.
- CNA certification: A Board approved training program of at least 100 hours (60 classroom and lab, 40 supervised clinical) and a passed competency evaluation. Since April 2026, Maryland certifies CNA-I and CNA-II levels; a CNA-II may not work in a nursing facility but can work in home care.
- Medication technicians: A certified medication technician completes a Board approved 20 hour training program. Medicaid personal assistance workers who give medications must be CMTs; workers doing other delegated nursing tasks must be CNAs.
- Agency training: Every caregiver is trained in personal care, when to call the nurse, record keeping, ethics and confidentiality, CPR, infection control and preventing abuse and neglect. Training from an outside source needs OHCQ's written approval.
- Background checks: Health-General §19-1902 requires a State criminal history records check or a private agency background check, plus a reference from the last employer, before an unlicensed caregiver starts work. Community First Choice agencies must use the State check for every direct service worker, nurses included.
- Medicare home health aides: Aides in a Medicare certified home health agency need at least 75 hours of training, including 16 hours of supervised practical training, a competency evaluation and 12 hours of in service training a year (42 CFR 484.80).
Six mistakes that slow Maryland agencies down
We look for every one of these in the first week of an engagement.
Sending uncertified aides to clients who need a CNA
- What it costs
- A deficiency on your first OHCQ inspection and clients you must restaff overnight.
- How we prevent it
- A nurse assessment workflow that records the certification decision, and waiver forms that meet COMAR 10.07.05.12.
Missing nurse supervision visits
- What it costs
- Citations for the 45 day, 3 month or 4 month visits, most often for clients whose medications staff give.
- How we prevent it
- A tracker that schedules each client's supervision visit from the medication level in the plan of care.
Filing an incomplete OHCQ application
- What it costs
- OHCQ holds it for 180 days and then closes it, and handwritten applications are returned.
- How we prevent it
- We assemble the business plan, policies, SDAT letter, insurance pages and RSA Certification before anything is filed.
Skipping the RSA Certification
- What it costs
- No license, even if you plan to hire only employees, because Health-General §19-4A-11 makes it a condition of licensure.
- How we prevent it
- We schedule the online certification with your owner or payroll lead as part of the application.
Advertising without your license number
- What it costs
- Exposure to civil money penalties under COMAR 10.07.05.06, and the same for calling yourself a home health agency.
- How we prevent it
- Marketing and Google Business Profile copy that carries your license number and OHCQ's required statement.
Planning Medicaid around the old ePREP process
- What it costs
- Weeks lost on drafts that never transferred to MPRIME, then billing delays without LTSSMaryland EVV.
- How we prevent it
- We file in MPRIME and set up your LTSSMaryland portal and EVV training before your first participant starts.
In a free 30 minute call we confirm your Maryland path, flag the mistakes that apply to your plan, and give you a fixed price to handle the rest.
Maryland launch packages
Three fixed price packages, matched to the path you choose. Your exact price is quoted in writing after your free call, before any work starts.
Private pay launch
For nonmedical agencies serving families who pay privately.
- Maryland path and a dated launch plan
- Policy and procedure manual written to COMAR 10.07.05 and COMAR 10.09.84
- Service agreement, client rights and care plan forms
- Caregiver hiring and screening workflow
- Google Business Profile setup
Community First Choice ready agency
Everything in Private pay launch, plus the Medicaid route.
- Policies aligned to Community First Choice requirements
- Caregiver training and background check tracker
- Medicaid provider enrollment
- Credentialing packets for Maryland Medicaid directly, as a Provider Type 76 personal assistance agency
- Survey and audit readiness
- Maryland city pages for local search
Home health and Medicare
For skilled home health. Hospice is scoped separately.
- Staffing and capital timeline
- Policies written to OHCQ rules and the Medicare Conditions of Participation
- License application and inspection readiness
- Accreditation survey preparation
- Medicare and Medicaid enrollment support
Every package: one fixed price agreed in writing · you own 100% of your agency · no franchise fees or royalties.
On your own vs a franchise vs Lunaria
| Topic | On your own | Home care franchise | With Lunaria |
|---|---|---|---|
| Who owns the business | You | You, under the franchisor's brand and rules | You, 100% |
| Ongoing fees | None | Royalties and brand fees, usually a share of revenue | None. One fixed project fee |
| Knowing what Maryland requires | Pieced together from manuals and forums | A national playbook, adapted | Confirmed on your first call, then in writing |
| Policy manual | A template, often from another state | The franchisor's standard manual | Written to COMAR 10.07.05 and COMAR 10.09.84 |
| Medicaid credentialing | One application at a time | Varies by franchisor | Packets for Maryland Medicaid directly, as a Provider Type 76 personal assistance agency prepared together |
| Your brand and marketing | Up to you | The franchisor's brand, with territory limits | Your brand, plus local search set up for you |
The Maryland home care startup checklist
Every Maryland step in order: business setup, your payer path, policies, caregiver screening and training, Medicaid enrollment and getting found. The items to start first are starred.
- Choose your services and payer mix (private pay, Community First Choice, or both)
- Form your LLC or corporation with SDAT through Maryland Business Express
- Get an EIN; register for withholding, unemployment insurance (BEACON) and FAMLI
- Order your SDAT good standing letter
- Buy workers' compensation, general and professional liability, and auto coverage
- and 15 more steps
Christine Ochimas, RN, LMFT, MBA
Christine founded Lunaria Care Consulting to give nurses and caregivers a direct route from "I want my own agency" to a compliant business with clients. She reads state requirements the way a reviewer does and writes policies the way a nurse would actually use them.
- We serve owners in all 50 states and DC, with a plan written for Maryland
- We help through enrollment and survey readiness, not just the application
- We tell you what we cannot promise: no one can guarantee a state or health plan decision
Have these ready for your consultation
- The care you want to provide and the clients you want to serve
- The Maryland cities or counties you plan to cover
- Where you are now: idea, business formed or already operating
- Who you expect to pay: families, Community First Choice, Medicare
- Your target opening month and rough budget
No client or patient records. We never need them for a first call.
What it costs to start a home care agency in Maryland
| Item | Notes |
|---|---|
| OHCQ license | OHCQ's current RSA application says there is no fee to apply. COMAR 10.07.05.04 lists a $1,000 nonrefundable fee for each 3 year license term and for renewal, and $250 for each extra prelicensure visit. Confirm with OHCQ which fees apply to you. |
| Entity formation and good standing | SDAT filing fees and the fee for the good standing letter through Maryland Business Express |
| Registered nurse | Assessments, plans of care, delegation and supervision visits for every client who needs skilled services or help with daily activities |
| Certified caregivers | CNA and CMT wages, and training program and Board fees if you sponsor certification |
| Background checks | State criminal history records check or private agency background check fees per caregiver, paid by the agency |
| Insurance | Workers' compensation, general and professional liability, auto coverage |
| Certificate of Need (home health, hospice) | MHCC application costs and consultant or legal fees before licensure |
| Accreditation (home health, hospice) | Accrediting organization application and survey fees |
| Operating reserve | Covers payroll, rent and insurance while OHCQ licensure, Medicaid enrollment or Medicare enrollment are pending |
Fees change. Confirm current amounts with each agency before budgeting.
How long it takes in Maryland
Months: OHCQ does not publish a processing time, and a complete application with policies and a nurse in place is the biggest factor you control.
Several months: the RSA license first, then MPRIME enrollment (Maryland Medicaid cites 2 to 6 weeks on average, depending on risk level) and LTSSMaryland EVV setup.
Longest: MHCC Certificate of Need on the Commission's review schedule, OHCQ licensure and survey, certification survey and Medicare enrollment, subject to any CMS moratorium.
Maryland's agencies compete hardest along the Baltimore and Washington corridor, where families have many licensed options and hospitals discharge patients home every day. OHCQ has reminded hospital and nursing home discharge planners to confirm that any home care agency they use holds the right license, so a clean RSA license and a clear list of services matter for referrals. Western Maryland, Southern Maryland and the Eastern Shore cover long distances, and reliable staffing is the selling point there. Families search by county and town, so Google Business Profile and county pages for Montgomery, Prince George's, Anne Arundel, Baltimore County and your other areas matter.
Frequently asked questions
Do I need a license to start a home care agency in Maryland?
Yes, if you provide personal care, home health aide services, nursing or any other home health care service. You need a Residential Service Agency license from OHCQ under COMAR 10.07.05. Agencies limited to household and family support services, such as housekeeping, meals, shopping and errands, do not need a license.
How much does a Maryland Residential Service Agency license cost?
OHCQ's current application says there is no fee to apply. COMAR 10.07.05.04 lists a $1,000 nonrefundable fee for each 3 year license term and at renewal, and OHCQ may charge $250 for each extra prelicensure visit. Confirm the current fees with OHCQ before you budget.
Do Maryland caregivers need to be CNAs?
Often, yes. COMAR 10.07.05.10 requires a certified caregiver, such as a CNA or certified medication technician, for a client who needs one for daily activities or medication administration. An uncertified worker is allowed only in limited cases, such as when the supervising nurse finds no predictable adverse health consequences or a capable adult client signs a waiver.
How long does it take to get an RSA license in Maryland?
OHCQ does not publish a standard processing time. A complete application moves fastest. An incomplete one is held for 180 days from receipt and then closed, and you would have to start a new application.
Can a Maryland RSA bill Medicaid?
Yes. A licensed RSA that employs a registered nurse can enroll with Maryland Medicaid in MPRIME as a personal assistance provider (Provider Type 76) and serve participants in Community First Choice, Community Personal Assistance Services and the Home and Community-Based Options Waiver. Workers clock in and out through LTSSMaryland EVV.
Does Maryland require a Certificate of Need for home health or hospice?
Yes. A new home health agency needs a Certificate of Need or an exemption from the Maryland Health Care Commission before OHCQ will license it, and so does a general hospice care program. A Residential Service Agency does not need one.
Can I open a Medicare certified home health agency or hospice in Maryland now?
CMS placed a nationwide moratorium on new Medicare enrollment of home health agencies and hospices from May 13, 2026, for six months unless extended, so it may have ended or been extended by the time you read this. Maryland adds a Certificate of Need before licensure. Check the CMS moratoria page before you plan around Medicare.
Is a franchise a better way to start a home care agency in Maryland?
A franchise gives you a brand and playbook in exchange for fees and ongoing royalties. Starting independently with Lunaria costs one fixed price, and you own 100% of your agency with no franchise fees or royalties.
How much does Maryland home care consulting cost?
Lunaria charges one fixed price per engagement, based on your path: private pay, Community First Choice or home health and Medicare. You receive the price in writing after a free 30 minute consultation. There are no hourly charges.
Do you only work in Maryland?
No. Lunaria works with owners in all 50 states and DC, so you can expand into Virginia, DC or another state with the same team.
Sources checked for this guide (48)
- OHCQ Residential Service Agencies page (application, RSA Certification, change of ownership, complaint hotline)
- OHCQ Application for a Residential Service Agency License (rev. 06.26.2026)
- OHCQ Home Health Agencies page
- OHCQ Application for a Home Health Agency License (rev. 03.18.2026)
- OHCQ Hospices page
- OHCQ Limited Hospice Care Programs page
- OHCQ transmittal: Discharge Planning Requirements and Reporting (March 24, 2026)
- COMAR 10.07.05.02, RSA definitions
- COMAR 10.07.05.03, license required
- COMAR 10.07.05.04, licensing procedures and fees
- COMAR 10.07.05.06, public representation and advertising
- COMAR 10.07.05.08, administration and policies
- COMAR 10.07.05.10, employee screening and certified caregivers
- COMAR 10.07.05.11, training
- COMAR 10.07.05.12, services, nursing supervision and on call
- COMAR 10.07.10.02 and .04, home health agency definitions and licensure
- COMAR 10.07.21.03 and .04, hospice license types and Certificate of Need
- COMAR 10.24.01.02, projects that require a Certificate of Need
- COMAR 10.24.01.07 and .08, Certificate of Need letters of intent and review schedules
- COMAR 10.24.16, State Health Plan: Home Health Agency Services
- COMAR 10.09.84.05 and .06, Community First Choice provider conditions
- COMAR 10.09.84.24, Community First Choice payment and telephonic timekeeping
- COMAR 10.67.06, HealthChoice MCO benefits (home health .05, hospice .23)
- COMAR 10.67.08.03, services paid fee for service outside HealthChoice
- COMAR 10.39.01, nursing assistant certification (CNA-I and CNA-II)
- COMAR 10.39, Board of Nursing certificate holders (CNA training program hours, medication technicians)
- Health-General §19-1901, adult dependent care program definitions
- Health-General §19-1902, criminal history or private background checks
- Maryland Medicaid Community First Choice page and overview (February 2026)
- Maryland Medicaid Community Personal Assistance Services overview (February 2026)
- Maryland Medicaid CFC provider information (PT 76, independent provider applications closed)
- Maryland Medicaid provider enrollment page (MPRIME)
- Maryland Medicaid Provider Enrollment FAQ (October 2026)
- Maryland Medicaid transmittal PT 28-27: final ePREP access deadline and MPRIME launch (September 16, 2026)
- LTSSMaryland Provider Portal Reference and User Guide, CO and CFC, v2.5 (August 2025)
- Maryland Medicaid LTSSMaryland training page
- CMS letter to Maryland Medicaid on EVV compliance (February 27, 2024)
- Maryland Department of Labor, earned sick and safe leave FAQs
- Maryland Department of Labor, new employers: unemployment insurance and FAMLI
- Maryland Business Express, tax accounts and insurance
- CMS Provider Enrollment Moratoria page (HHAs and hospices, May 13, 2026; last modified August 27, 2026)
- Federal Register 2026-09717: nationwide moratorium on Medicare enrollment of home health agencies
- Federal Register 2026-09718: nationwide moratorium on Medicare enrollment of hospices
- 42 CFR 484.80, home health aide training and competency (Cornell LII)
- 42 CFR Part 484, home health Conditions of Participation (Cornell LII)
- 42 CFR Part 418, hospice care (Cornell LII)
- 42 CFR 489.28, initial reserve operating funds for HHAs (Cornell LII)
- CMS-855A Medicare enrollment application, institutional providers
This guide is general information and reflects Maryland requirements as we understood them in November 2026. Requirements change. Confirm current rules, fees and procedures with the Maryland Department of Health, Office of Health Care Quality, Maryland Medicaid, the Maryland Health Care Commission and CMS before filing. Lunaria Care Consulting provides professional consulting services and does not provide legal advice.
Other states: see all state guides. What we do: licensing, compliance, Medicaid enrollment and local search marketing.