Maryland's Certificate of Need: MHCC Review and the OHCQ Licensure Handoff
Maryland's Certificate of Need (CON) program separates the planning/approval function from the operational licensure function into two distinct agencies: the Maryland Health Care Commission (MHCC) administers CON under Md. Health-General Article § 19-101 et seq. and COMAR 10.24, while the Office of Health Care Quality (OHCQ) handles facility licensure and ongoing oversight. The separation matters because a CON approval gets a project built; OHCQ licensure lets the completed facility open. This essay walks the MHCC review, project categories, capital thresholds (updated to $12.4M for hospitals and $6.2M for non-hospitals as of 2025), and the MHCC-OHCQ coordination.
The statutory framework
- Md. Health-General Article § 19-101 et seq. — CON statute.
- COMAR 10.24 — implementing regulations.
- Maryland Health Care Commission (MHCC) — administers CON, reviews proposed projects, makes decisions.
- Office of Health Care Quality (OHCQ) — handles facility licensure, inspections, and ongoing regulatory oversight.
Primary source: mhcc.maryland.gov.
What requires a CON
CON is generally required for:
- Building, developing, or establishing a new health care facility.
- Moving an existing facility to another site.
- Changing bed capacity.
- Changing the type or scope of any health care service offered.
- Capital expenditure exceeding the statutory threshold.
Facility categories covered:
- Hospitals.
- Limited service hospitals.
- Related institutions.
- Ambulatory surgical facilities.
- Rehabilitation facilities.
- Home health agencies.
- Hospices.
Specialized hospital services with their own CON requirements include cardiac surgery, organ transplant, and neonatal intensive care.
The capital thresholds
As of April 2025:
- Hospitals — CON required for expenditures over $12.4M.
- Non-hospitals — CON required for expenditures over $6.2M.
- These catch-all thresholds apply when no specific CON requirement matches.
- Exemptions exist for capital expenditures not directly related to patient care, expenditures not changing patient charges, or certain major medical equipment acquisitions.
Thresholds update periodically; verify current figures with MHCC before scoping.
Review criteria
MHCC evaluates applications against:
- State Health Plan — standards, policies, criteria.
- Need — applicable need analysis; absent specific analysis, applicant demonstrates unmet need in service area population.
- Cost-effective alternatives — comparison with existing facilities and competitive applications.
- Viability — financial and non-financial resources to complete and sustain.
- Compliance history — demonstrate compliance with prior CON conditions and commitments.
- Impact on existing providers — geographic/demographic access, occupancy, costs, charges.
- Social determinants of health — how SDOH creates healthcare disparities in the service area.
- Character and competence — applicant's experience, past performance, violation history.
The SDOH criterion is a distinctive Maryland addition — MHCC explicitly considers how the proposed project affects health disparities.
The review process
- Letter of Intent.
- Pre-application conference with MHCC staff (strongly encouraged).
- Application submission.
- Completeness review and applicant response.
- Public comment period — 30 days.
- Reviewer appointment if interested parties engage.
- Staff report and recommendation (or Reviewer's Recommended Decision).
- Project Status Conference if required.
- Exceptions and responses by parties to the recommendation.
- Commission decision.
Timeline: up to 90 days if competitors don't request an evidentiary hearing, or 150 days if a hearing is requested.
Review cycles
Applications outside specific review schedules can be submitted at any time; scheduled reviews follow published MHCC schedules. MHCC publishes schedules for different project types, and pre-filing consultation with Commission staff is strongly encouraged.
MHCC-OHCQ relationship
The two agencies have distinct but coordinated roles:
MHCC
- Administers CON.
- Reviews proposed projects and acquisitions for need, quality, and financial viability.
- For nursing home acquisitions, provides a report and recommendation to OHCQ and the Office of the Attorney General — including findings on CMS star-ratings, inspection reports, and lawsuit history.
OHCQ
- Licenses and surveys health care facilities.
- Conducts health and fire safety inspections for federal and state regulatory compliance.
- Ensures residents receive safe, quality care.
- Role in Change of Ownership (CHOW) for nursing homes.
- Receives MHCC findings and recommendations to inform licensure review and oversight.
The practical pattern: MHCC gates project existence; OHCQ gates operational status. A project with MHCC CON approval still needs OHCQ licensure before opening. See our CON vs Licensure Distinction essay for the broader structural separation.
What developers and operators should know
- MHCC pre-filing consultation is strongly encouraged — take the meeting.
- State Health Plan conformance is the single biggest review factor. Read the relevant SHP chapter before filing.
- SDOH analysis is part of the review. Document how the project addresses disparities.
- Competitive review triggers evidentiary hearing and 150-day timeline (vs 90).
- Prior CON compliance matters. Non-compliance with previous CON conditions is a substantive review factor.
- OHCQ licensure follows after construction — not substituted by CON approval.
- Thresholds change. Verify $12.4M hospital / $6.2M non-hospital catch-all against current MHCC rules.
Nursing home CHOW considerations
Nursing home ownership changes receive particular attention. MHCC reviews the acquiring entity's CMS star-ratings, inspection reports, and lawsuit history. MHCC findings are transmitted to OHCQ and the OAG. The acquisition may proceed, be conditioned, or be blocked based on the review. Operators acquiring MD nursing homes should expect substantial diligence on their operating history.
How MD CON compares to the other Mid-Atlantic states
- Virginia COPN. Seven batching groups, 120/190-day windows, DCOPN. See our VA COPN essay.
- New Jersey CN. Full/expedited review split, 12 monthly cycles, substantial exemption map. See our NJ CN essay.
- Delaware CPR. HRB administration, $5.8M inflation-adjusted threshold. See our DE CPR essay.
- Pennsylvania. No CON — repealed 1996. Licensure only.
- Maryland CON. MHCC-OHCQ separation, SHP conformance focus, SDOH review, $12.4M/$6.2M catch-all thresholds.
For the broader five-state picture, see our Certificate of Need Across the Mid-Atlantic essay.
What to do with this
If you're planning MD healthcare capital work: threshold check first, then SHP conformance review, then pre-filing consultation with MHCC.
If acquiring an MD facility (especially nursing home): expect MHCC diligence on operational history. Budget for the review.
If you're competitive with another applicant: prepare for 150-day review and evidentiary hearing.
If you have prior MD CON conditions: document compliance demonstrably.
For OHCQ licensure side, see our CON vs Licensure essay.
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