Certificate of Need Across the Mid-Atlantic: Five States, Five Approaches

Why CON exists, briefly

Certificate of Need programs were created to constrain unnecessary duplication of healthcare capital capacity — the theory being that unlimited buildout of hospital beds, imaging equipment, and surgical capacity drives overutilization and cost. The federal mandate that created state CON programs was repealed in the 1980s; since then, each state has either kept, modified, or abandoned its CON program on its own timeline. Pennsylvania abandoned its traditional CON program; every other state in our Delaware Valley footprint retained or restructured theirs.

What that means operationally: whether your hospital expansion requires CON approval depends entirely on which state the project sits in. Similar projects in different states face dramatically different pre-construction timelines.

Pennsylvania: no traditional CON

Pennsylvania is the outlier. PA does not operate a traditional Certificate of Need program. Healthcare facility projects in Pennsylvania move directly into PA DOH facility licensure and local permit processes without a separate needs-based review upstream.

For health systems that grew up in Pennsylvania, this is the default assumption about how things work. When those same systems cross into New Jersey, Maryland, or Virginia, the CON step surprises them. If you've run a dozen projects in PA without CON experience, your first NJ or VA project will have a CON timeline you haven't built into the master schedule.

New Jersey: active CN, DOH-administered

New Jersey maintains an active Certificate of Need program, administered by the New Jersey Department of Health. CN applicability depends on the project category and service-line additions; capacity additions (beds, operating rooms, certain services) typically trigger CN review.

NJ's CN is administered by the same agency that will eventually license the facility, which simplifies agency coordination compared to Maryland's split model. But the review itself takes months, involves utilization analysis and community need demonstration, and binds the approved project scope — you cannot freely expand bed count or add operating rooms mid-design after CN is approved.

Maryland: two-agency structure, MHCC + OHCQ

Maryland is the most structurally distinctive Mid-Atlantic CON regime. The Maryland Health Care Commission (MHCC) runs CON review. The Maryland Office of Health Care Quality (OHCQ), under the Maryland Department of Health, runs licensure.

That's two separate agencies with two separate processes, and contractors need relationships with both. A project that needs CON approval from MHCC then goes to OHCQ for facility licensure and construction plan review. Skipping MHCC or assuming OHCQ handles both is the single most common out-of-state mistake on Maryland healthcare construction.

MD CON applies to new hospitals, hospital bed additions, nursing home capacity changes, ambulatory surgical centers above the OR threshold, and certain high-cost services. The threshold specifics should always be verified against current MHCC regulations before assuming the project is CON-exempt.

Virginia: Certificate of Public Need (COPN), single-agency

Virginia calls it Certificate of Public Need (COPN), not CON. The program is administered by the Virginia Department of Health — the same agency that handles licensure and CMS surveys. VDH runs everything under one roof, which simplifies coordination compared to Maryland's split.

COPN applies to a broad set of projects: hospitals, ASCs (which in Virginia are licensed as "outpatient surgical hospitals" under 12VAC5-410 Parts IV-V, not as a separate category), nursing facility beds, and many services. The COPN review process involves community need demonstration, utilization projections, and specific regulatory findings. Like MD and NJ, scope is bound by the approved COPN — downstream design changes that exceed approved scope require COPN amendment.

Delaware: narrower CN scope

Delaware operates a Certificate of Need program, administered through the Delaware Health Resources Board, but the scope is narrower than NJ, MD, or VA — fewer project categories trigger CN review. DHSS Division of Health Care Quality handles licensure; CN runs through the Board separately.

The practical consequence: many Delaware healthcare projects that would require CN in Maryland or Virginia do not require CN in Delaware. That makes DE somewhat more flexible for capacity additions but the CN evaluation still has to happen on a project-by-project basis; don't assume exemption without checking.

Implications for project schedules

A Certificate of Need or COPN application typically takes months from complete filing to decision — longer if the project is contested or requires public hearings. That timeline happens before the design is substantially locked, because the CN-approved scope constrains downstream design decisions. Key scheduling implications:

• CN evaluation is the first activity on any multi-state healthcare project. Run it concurrently with early programming, not after schematic design.
• Scope is bound by the approved CN. Adding beds, operating rooms, or service lines mid-design means returning to the CN body for amendment, which adds more months.
• Pre-application consultation is worth it. Every state's CN agency offers pre-application meetings; use them. Scoping the application correctly at filing cuts review time.
• For multi-state systems, CN applies per state. A New Jersey hospital expanding a service line that also adds capacity in Maryland needs two separate reviews.
• Pennsylvania's no-CN status is a comparative advantage for capacity-driven projects. A service expansion feasible in PA may be timeline-constrained in neighboring states.

Implications for design

CN-approved scope locks bed counts, operating room counts, and service types. Design teams that get ahead of CN on programming can find themselves designing a facility that won't be approved as proposed. A few design-side adjustments:

• Defer decisions on exact OR count, patient bed count, or imaging suite count until CN is approved or at least scoped.
• Design for flexibility within CN-approved parameters — shell space, convertible rooms — rather than maxing out specific numbers that CN might constrain.
• Build CN-application drawings as a specific deliverable; they may need to be more detailed than a typical pre-schematic package.
• Document community need demonstration materials early; the applicant will need them to support CN filing and will need them again at utilization reviews post-opening.

What to do with this

If you're running a healthcare construction project in the Mid-Atlantic: identify the CN regime for every state where work will be performed before committing significant design resources. In PA, plan to skip the step. In NJ, MD, VA, and (narrowly) DE, plan the CN/COPN review into the critical path.

For the per-state detail, see:

• Delaware Healthcare Facility Licensure Navigator
• Pennsylvania Healthcare Facility Licensure Navigator
• New Jersey Healthcare Facility Licensure Navigator
• Maryland Healthcare Facility Licensure Navigator
• Virginia Healthcare Facility Licensure Navigator
• Mid-Atlantic Healthcare Facility Licensure Compared

About The Hive

The Hive builds tools and publishes essays for working healthcare construction and MEP professionals in the Delaware Valley. We don't do CN consulting; we just want the regulatory landscape to be legible for people doing the actual work. Email us topics you'd like covered.