Last updated 2026-07-25
TL;DR
MDH assisted living refers to Maryland Department of Health licensing of assisted living programs under COMAR 10.07.14. Maryland assigns each resident a Level 1, 2, or 3 based on acuity, requires a manager credential, and inspects annually. It is not the same as a nursing home license, and Medicare does not pay for the room and board portion.
What is MDH assisted living?
MDH assisted living is the licensing program the Maryland Department of Health runs for assisted living facilities under Code of Maryland Regulations (COMAR) 10.07.14. MDH's Office of Health Care Quality (OHCQ) is the division that actually issues the license, inspects the building, and investigates complaints [1]. Maryland does not license "group homes for seniors" as a separate category. If you are housing three or more unrelated adults and providing help with bathing, dressing, medication, or meals in exchange for payment, you almost certainly need an assisted living license, not a boarding house permit. COMAR defines an assisted living program as one that provides "a level of service, care, or treatment that exceeds what is required by an independent household" for people who need help with activities of daily living [2]. Maryland separates its assisted living population into three levels of care, Level 1, Level 2, and Level 3, based on how much medical and personal care a resident needs. This matters more in Maryland than in most states because your staffing ratios, admission agreements, and even your physical plant requirements shift depending on which level residents you're licensed to serve. If you're comparing Maryland's approach to other states, our state licensing guides hub breaks down how different agencies structure their tiers.
What is assisted living?
Assisted living is a residential care option for adults, usually seniors, who need help with daily activities like bathing, dressing, medication management, or meal preparation, but who don't need the round-the-clock skilled nursing care a hospital or nursing home provides. Residents typically live in private or semi-private rooms or apartments and pay for a bundle of housing, meals, and personal care services. Every state licenses assisted living differently, and there's no federal assisted living statute. The Centers for Medicare & Medicaid Services (CMS) confirms this directly: "States, not the federal government, are primarily responsible for regulating assisted living" [3]. That's why the name changes state to state: Maryland calls it an assisted living program, California calls it a residential care facility for the elderly, some states call it a personal care home. The service model is similar; the paperwork is not. In Maryland, assisted living sits between independent senior housing and a nursing facility on the care spectrum. It's licensed by MDH, inspected by OHCQ, and governed by COMAR 10.07.14, not by the Office of Long Term Care Facility rules that apply to nursing homes.
What is a group home?
A group home is a licensed residential setting where a small number of unrelated people, often people with intellectual or developmental disabilities, mental illness, or substance use disorders, live together and receive support staff supervision. The term gets used loosely, but in most state regulatory schemes, "group home" refers to a different license category than "assisted living," even though the physical setup can look nearly identical from the street. In Maryland, group homes for people with developmental disabilities are licensed through the Developmental Disabilities Administration (DDA), a different unit inside MDH than the one that licenses assisted living. Group homes for behavioral health populations go through the Behavioral Health Administration. Assisted living, by contrast, is specifically aimed at people (mostly older adults) needing personal care and supportive services, licensed under COMAR 10.07.14 through OHCQ [1]. If your business plan mixes populations, say, you want to serve both seniors aging in place and younger adults with intellectual disabilities, you likely need two separate licenses, possibly from two different administrations within MDH, each with its own application, inspection cycle, and staffing rule. Don't assume one license covers both. Confirm with your state licensing agency before you sign a lease or start marketing beds.
What is an assisted living facility?
An assisted living facility is the physical building and program combination: the licensed home or facility where residents live and receive assisted living services. It's more than real estate. A building only becomes an "assisted living facility" in the legal sense once the state issues a license tied to that specific address, operator, and (in Maryland's case) approved capacity and level of care. Maryland's COMAR 10.07.14 defines the physical plant requirements alongside the service requirements: minimum square footage per resident bedroom, bathroom-to-resident ratios, and fire and life safety standards that get checked against the National Fire Protection Association's Life Safety Code during inspection [2]. A facility licensed for four Level 1 residents cannot simply start admitting Level 3 residents needing two-person transfers; the license specifies both capacity and level. If you're researching options for a family member, our assisted living facilities overview compares what to expect walking into a licensed building versus an unlicensed boarding arrangement, which matters because unlicensed operators exist and they carry real risk for residents and families.
What is assisted living facility (the licensing category, explained plainly)?
"Assisted living facility" as a licensing category means the state has reviewed and approved a specific location to provide personal care services to residents who need help with daily living but don't require hospital-level or skilled nursing care. It sits in the middle of the long-term care continuum: independent living on one end, skilled nursing on the other. Maryland's version of this category has three sub-levels built in, which is somewhat unusual. Most states use one blanket "assisted living" license and let acuity be managed informally or through a separate memory care endorsement. Maryland instead assigns every resident a level (1, 2, or 3) based on a standardized assessment, and the facility's license reflects which levels it's approved to serve [2]. This level system exists because Maryland wants a documented, auditable trail showing that a resident's needs match the level of staffing and physical plant the facility actually has. It also protects operators: if OHCQ shows up and a resident's needs have drifted beyond what the facility is licensed for, having a current, dated level-of-care assessment on file is your evidence that you were compliant at last review.
How do the three MDH assisted living levels of care work?
| Level 1 | Needs help with some ADLs (bathing, dressing), largely mobile and cognitively intact or mildly impaired | Lowest staff-to-resident ratio requirement | |
|---|---|---|---|
| Level 2 | Needs more extensive help with ADLs, may have moderate cognitive impairment, may need some nursing oversight | Moderate staffing, more direct care hours | |
| Level 3 | Needs extensive help with ADLs, may be non-ambulatory, may need two-person assist or more intensive nursing oversight | Highest staffing and often requires a nurse on a more regular basis | A facility must be licensed for the specific level(s) it wants to serve, and a resident's assessed level can change over time. If a Level 1 resident declines and now needs Level 3 care, the facility either has to be licensed for Level 3 or has to work with the resident's family and physician on a transfer plan. This is one of the more common inspection findings OHCQ cites: residents whose care needs have exceeded what the facility's license and staffing actually support. |
Maryland's three levels correspond to how much hands-on care and supervision a resident needs, not to a fixed dollar amount or bed type. Here's the rough breakdown, drawn from COMAR 10.07.14 and the level-of-care assessment tool OHCQ requires facilities to use. | Level | General resident profile | Typical staffing implication |
How to start a group home / assisted living program in Maryland
Starting an MDH-licensed assisted living program is a multi-step process, and skipping steps (or doing them out of order) is the single most common reason applications stall. Here's the realistic sequence, though you should always confirm exact requirements with your state licensing agency since regulations and fee schedules get updated. 1. Decide your service population and level(s) of care. This drives everything downstream, your physical plant needs, staffing plan, and which license you actually need (assisted living versus a DDA or behavioral health group home license). 2. Line up your property and confirm zoning. Assisted living homes usually fall under residential care use in local zoning codes, but county and municipal rules vary widely across Maryland's 23 counties plus Baltimore City. A property that's zoned fine for a single-family home is not automatically zoned for a licensed care facility with paid staff and multiple unrelated residents. Check with your local planning and zoning office before you sign a lease. Our zoning and property guidance covers the general questions to ask, but county-level answers only come from your county. 3. Get your manager credential. Maryland requires assisted living managers to complete state-approved training and hold a manager certificate; the specifics (hour requirements, renewal cycle) are set by OHCQ and should be confirmed directly since training hour requirements have changed over the years [1]. 4. Build your policy and procedure manual. This covers admission and discharge criteria, medication management, emergency and disaster planning, staffing plans by shift, and resident rights disclosures required under COMAR. Reviewers will ask for this before they schedule your pre-licensing inspection. 5. Submit your license application to OHCQ, including the required application fee (confirm the current fee schedule directly with OHCQ, as fees are set by regulation and periodically updated) [1]. 6. Pass the pre-licensure inspection. OHCQ inspects for life safety code compliance, physical plant adequacy, and whether your written policies match what's actually happening on site. 7. Get your license and start operating within your approved level(s) and capacity. If you want a structured way to organize the policy manual, staffing plan, and application paperwork across this whole sequence, GroupHomePath's $299 State Group Home Licensing Kit gives you editable templates built around what state agencies actually ask for, so you're not building every form from a blank page.
How do I start a group home? (step-by-step for other states)
If you're outside Maryland, the sequence is similar but the agency names and specific rules change. Every state requires: (1) a business entity and tax registration, (2) a facility license from the state health or social services agency, (3) local zoning approval, (4) a fire marshal or life safety inspection, (5) staff background checks and training documentation, and (6) a written policy and procedure manual covering admission, medication, emergency response, and resident rights. What differs enormously is which state agency handles licensing (health department, aging services, social services, or a mix), whether the state uses a tiered level-of-care system like Maryland's, and how frequently the state re-inspects. Some states license by bed count tiers; others license uniformly regardless of size. Application fees range widely, commonly in the low hundreds to low thousands of dollars depending on the state and facility size, so don't budget based on a number you saw for a different state. The honest starting point is always your specific state licensing agency's assisted living or residential care licensing page, not a national blog post, because the rules genuinely differ by state and even by county for zoning. Our assisted living hub links out to state-specific breakdowns if Maryland isn't your state.
What does assisted living provide?
Assisted living typically provides housing (private or shared room), meals, help with activities of daily living (bathing, dressing, toileting, transferring), medication management or reminders, housekeeping and laundry, social and recreational activities, and staff supervision available on a scheduled or on-call basis depending on the facility's level of licensure. What it does not typically provide, at least not as a baseline, is skilled nursing care, rehabilitation therapy, or hospital-level medical monitoring. Some assisted living facilities contract with home health agencies to bring in nursing or therapy services for residents who need them temporarily, but that's an add-on, not the core license. In Maryland specifically, what a facility can provide is tied directly to its licensed level. A Level 1 facility can't market itself as able to handle residents who need two-person transfers or complex wound care; that's Level 3 territory and the facility needs to be licensed and staffed for it [2]. This is worth knowing as a consumer or operator: the marketing brochure and the actual license scope have to match, and OHCQ checks for that mismatch during complaint investigations.
What is the difference between assisted living and nursing home?
The core difference is medical intensity. Assisted living is for people who need help with daily living tasks but are largely medically stable; a nursing home (skilled nursing facility) is for people who need ongoing medical care, rehabilitation, or supervision by licensed nursing staff around the clock. Licensing reflects that difference. Nursing homes are certified under federal Medicare and Medicaid Conditions of Participation, and CMS requires them to have a registered nurse on duty at least 8 consecutive hours a day, seven days a week, with licensed nursing services available 24 hours a day [4]. Assisted living has no equivalent federal staffing floor because there's no federal assisted living certification at all; it's purely state-by-state licensing [3]. Cost structure differs too. Assisted living is usually private-pay or covered in part by long-term care insurance or a state Medicaid home and community-based services waiver; nursing home care is more often covered by Medicare (short-term, post-hospital only) or Medicaid (long-term, once a resident qualifies financially and medically) [5]. Physically, nursing homes look and operate more like a medical facility; assisted living is designed to feel more like a residence.
Does Medicare cover assisted living facilities?
No. Medicare does not pay for the room, board, or personal care costs of assisted living. Medicare.gov states plainly that Medicare "doesn't cover long-term care (also called custodial care)" if that's the only kind of care a person needs, and assisted living is generally classified as custodial care [6]. What Medicare will cover, even for someone living in an assisted living facility, is medically necessary services that would be covered anywhere: doctor visits, physical therapy ordered by a physician, durable medical equipment, and short-term skilled nursing care after a qualifying hospital stay (but that skilled care has to happen in a Medicare-certified skilled nursing facility, not in the assisted living building itself, in most cases). Medicaid is a different story, and this is where it gets state-specific and genuinely confusing for families. Some states, through Medicaid Home and Community-Based Services (HCBS) waivers authorized under Section 1915(c) of the Social Security Act, will help cover the personal care services portion of assisted living, though almost never the room and board portion [4]. Maryland has its own HCBS waiver programs administered through the Maryland Department of Health; whether a specific assisted living resident qualifies depends on income, assets, and functional need, and that determination is made case by case. If you're building your funding model around Medicaid HCBS reimbursement, read our funding and Medicaid resources before you assume any specific dollar amount, because waiver availability and reimbursement rates change and eligibility rules are genuinely state-specific.
How does an MDH assisted living inspection work?
OHCQ conducts both scheduled licensing surveys and unannounced inspections in response to complaints. Facilities get inspected against the physical plant, staffing, and care standards in COMAR 10.07.14, and inspectors have authority to issue deficiency findings, require a plan of correction, or in serious cases suspend or revoke a license [1]. The things inspectors check most consistently: whether each resident's current level-of-care assessment matches services actually being delivered, whether medication administration records are accurate and current, whether staff have completed required training and background checks, whether the physical plant meets fire and life safety code, and whether required resident rights disclosures and admission agreements are on file and properly executed. If you want a general sense of how licensing inspections work across states (more than Maryland), our inspections hub walks through the common deficiency categories operators run into and how to prepare a facility ahead of a survey, whether it's announced or a surprise complaint visit.
How much does it cost to license an MDH assisted living program?
Costs break into several buckets, and none of them are trivial: the OHCQ application and licensing fee itself (confirm the current fee schedule directly with OHCQ since fee schedules are updated periodically by regulation), manager training and certification costs, physical plant modifications needed to meet fire and life safety code, staff background checks and required training hours, and the cost of building a compliant policy and procedure manual before your pre-licensure inspection. Most of the real cost in year one isn't the license fee itself, it's the physical plant work (sprinkler systems, egress modifications, bathroom accessibility) and the staffing you have to have hired and trained before OHCQ will schedule your pre-licensure inspection. Budget for a licensing timeline that can run several months from application to opening day, and don't sign a lease assuming a fast approval, because OHCQ inspects the actual physical plant and won't shortcut that for anyone.
What should I read next if I'm comparing states or planning a facility?
If Maryland isn't your state, or you're weighing whether assisted living or a different residential care license fits your business plan, start with the general assisted living facility overview and the senior assisted living facilities near me guide for consumer-facing context, and the assisted living at home piece if you're considering a smaller, home-based model rather than a larger facility. Whatever state you're in, the sequence is the same at a high level: confirm your population and level of care, confirm zoning before you commit to a property, get your manager or administrator credential, build a policy manual that actually matches your operations, and pass your inspection with your physical plant and staffing already in place, not promised. Getting the paperwork sequence right the first time saves months. GroupHomePath built the $299 State Group Home Licensing Kit around that exact sequence, with editable policy manual templates, staffing plan worksheets, and application checklists organized by what agencies actually request, so you're adapting a proven structure to your state instead of starting from scratch.
Frequently asked questions
What is assisted living?
Assisted living is residential care for adults who need help with daily activities like bathing, dressing, and medication management but don't need full-time skilled nursing care. Residents live in private or shared rooms and pay for housing, meals, and personal care support. States, not the federal government, regulate assisted living, so the name and rules vary by state.
What is a group home?
A group home is a licensed residential setting where a small number of unrelated people, often those with disabilities or behavioral health needs, live with staff support. It's typically a separate license category from assisted living, issued by a different state agency division, even though the buildings can look similar.
What is an assisted living facility?
An assisted living facility is a licensed building and program combination approved by the state to house residents and provide personal care services. The license ties to a specific address, operator, and approved capacity, and in states like Maryland, to a specific level or levels of care the facility is authorized to serve.
What is the difference between assisted living and a nursing home?
Assisted living serves people needing help with daily activities who are medically stable; nursing homes serve people needing ongoing skilled nursing care. Nursing homes must have a registered nurse on duty at least 8 hours daily per CMS Conditions of Participation. Assisted living has no equivalent federal staffing rule since it's regulated entirely at the state level.
Does Medicare cover assisted living facilities?
No. Medicare does not cover the room, board, or custodial care costs of assisted living, per Medicare.gov guidance on long-term care. Medicare will cover medically necessary services like doctor visits or therapy for someone who happens to live in assisted living, but not the assisted living stay itself.
How do I start a group home?
Decide your target population, secure a property that's properly zoned, get any required manager or administrator credential, build a compliant policy and procedure manual, submit your license application with required fees, and pass a pre-licensure inspection. Exact steps and agency names vary by state, so confirm requirements with your specific state licensing agency.
What is MDH assisted living exactly?
MDH assisted living refers to assisted living programs licensed by the Maryland Department of Health through its Office of Health Care Quality, under COMAR 10.07.14. Maryland uses a three-level system (Level 1, 2, 3) tied to resident acuity, and facilities are licensed to serve specific levels.
What are Maryland's three assisted living levels of care?
Level 1 residents need help with some daily activities and are largely mobile. Level 2 residents need more extensive help and may have moderate cognitive impairment. Level 3 residents need extensive assistance, may be non-ambulatory, and often require more regular nursing oversight. Staffing requirements increase with each level.
Is a group home the same as an assisted living facility?
Not usually. They're often licensed under different state agencies with different rules, even though both involve unrelated residents living together with staff support. Assisted living generally targets seniors needing personal care; group homes often serve people with intellectual, developmental, or behavioral health needs under a separate license.
Does Medicaid pay for assisted living in Maryland?
Medicaid may help cover the personal care services portion of assisted living through Home and Community-Based Services waivers, but almost never the room and board portion. Eligibility depends on income, assets, and functional need assessed case by case. Confirm current waiver availability and rules with the Maryland Department of Health.
How much does an MDH assisted living license cost?
Costs include the OHCQ application and license fee, manager training and certification, physical plant upgrades for fire and life safety compliance, staff background checks, and policy manual development. Confirm current fee amounts directly with OHCQ, since fee schedules are set by regulation and updated periodically.
What does assisted living provide that independent living doesn't?
Assisted living adds hands-on help with activities of daily living such as bathing, dressing, and medication management, plus staff supervision, on top of the housing and meals independent living already offers. Independent living residents are generally healthy enough to manage daily tasks without regular staff assistance.
Who inspects MDH assisted living facilities?
Maryland's Office of Health Care Quality (OHCQ), a division of the Maryland Department of Health, conducts both scheduled licensing surveys and unannounced complaint-based inspections of assisted living facilities under COMAR 10.07.14.
Sources
- COMAR 10.07.14 Assisted Living Programs: Definition of assisted living program and the three-level system with physical plant requirements
- CMS, Nursing Home and Assisted Living/Residential Care overview: States, not the federal government, are primarily responsible for regulating assisted living
- CMS, State Operations Manual Appendix PP, 42 CFR 483.35: Nursing homes must have a registered nurse on duty at least 8 consecutive hours a day, seven days a week
- Medicaid.gov, Home & Community-Based Services 1915(c): Section 1915(c) HCBS waivers can help cover personal care services in community settings like assisted living
- Medicaid.gov, Long Term Services & Supports: Medicaid can cover long-term care costs once a person qualifies financially and medically, distinct from Medicare's short-term coverage
- Medicare.gov, Long-term care coverage: Medicare doesn't cover long-term custodial care, which is how assisted living is generally classified