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Maryland Drug and Alcohol Outpatient Treatment Licensing

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A. Ant, CADC-II

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Author: A. Ant, CADC-II, Licensing & Accreditation Expert

Disclaimer: This content is provided for general informational purposes only and should not be construed as legal, regulatory, or licensing advice. Requirements change frequently. Consult qualified professionals for guidance specific to your situation.

Apply now: BHA has taken license applications online since February 10, 2025. Supporting forms sit on the BHA COMAR 10.63 forms page | Questions on the online application: bha.licensingcompliance@maryland.gov

Outpatient substance use disorder treatment in Maryland, including intensive outpatient and partial hospitalization, is licensed by the Maryland Department of Health, Behavioral Health Administration (BHA) under COMAR 10.63. Lower intensity does not mean a lighter process. Outpatient programs sit on the same accreditation-based track as residential ones. What they skip is the Certificate of Need question that hangs over a Level 3.7 build.

Three Outpatient Levels, One Accreditation-Based Structure

Outpatient LevelCOMAR 10.63 SectionCertificate of NeedAccreditation-Based License
Outpatient Treatment Level 110.63.03.06Not requiredYes
Intensive Outpatient Treatment Level 2.110.63.03.03Not requiredYes
Partial Hospitalization Treatment Level 2.510.63.03.07Not requiredYes

The weekly hours are what separate the three. COMAR caps Level 1 at fewer than 9 hours a week for adults (fewer than 6 for clients under 18), sets Level 2.1 at 9 to 20 hours for adults and 6 to 20 for minors, and puts Level 2.5 at 20 to 35 hours a week. Each of the three can also carry two add-on services, but only when the license names them: a Withdrawal Management Service, which at the ambulatory end of COMAR 10.63.03.18 means Level 1-WM or Level 2-WM, and an Opioid Treatment Service under 10.63.03.19.

Maryland also licenses an Integrated Behavioral Health Program (10.63.03.02). It has to meet the rules for both an outpatient mental health center and a Level 1 program, and it must be able to treat mental illness, substance use disorders, and the two together. If you plan to treat both populations in one clinic, ask BHA whether that category fits before you apply for two separate programs.

Accreditation Is the Entry Ticket

The outpatient track runs on the exact same gate as the residential one. BHA will not issue an accreditation-based license until the program holds accreditation from an approved organization. The Maryland Department of Health currently approves ACHC, CARF, the Council on Accreditation, and The Joint Commission for community programs (a fifth, the National Commission on Correctional Health Care, is approved for correctional facilities only). BHA’s accreditation-based licensing page carries a crosswalk for each accreditor, and its own warning is that not every accreditor is approved for every program type. Pick the accreditor from the crosswalk for the exact levels you will offer, and check any add-on service too, rather than assuming one approval carries across every outpatient level.

Certificate of Need Does Not Apply

The Maryland Health Care Commission described the reach of its Certificate of Need program for addiction treatment in a 2022 recommended decision: a CON was needed to establish or relocate an intermediate care facility (ASAM Level 3.7) or to establish, relocate, or add beds to a hospital-level Level 4 service. Since October 1, 2026, Chapter 69 of 2026 (House Bill 498) has also let an intermediate care facility offering medically managed residential treatment skip the CON by filing written notice 45 days ahead, as long as the Commission finds the plan is not inconsistent with the State Health Plan, would make care delivery more efficient, and serves the public interest. Neither that description nor the list of covered health care facilities in Health-General §19-114 names an outpatient, intensive outpatient, or partial hospitalization program, and our reading is that MHCC has no filing for one. An outpatient operator goes straight to accreditation and BHA.

The Agreement to Cooperate Is a Separate Local Step

Outpatient operators hit this same local requirement residential programs face, and it’s easy to miss until it blocks a filing. COMAR 10.63.01.05 puts it ahead of the application itself: before applying, you sign an Agreement to Cooperate with the Core Service Agency, Local Addictions Authority, or Local Behavioral Health Authority in every county, or Baltimore City, where you will operate. BHA’s form (DHMH #4781, revised July 31, 2025) is required with an initial application, a renewal, an added service, and any change to the license, which the form says covers locations, service array, and ownership. Where a county splits mental health and addiction oversight between a Core Service Agency and a Local Addictions Authority, with no Local Behavioral Health Authority, BHA’s Introduction to Accreditation and Licensing Requirements says a program providing both kinds of care must have a signed agreement from each office, so budget time for two signatures there. A second site or a second level of care added later also needs the Department’s approval in advance (COMAR 10.63.06.07), so a new lease or a new service line means a fresh agreement.

Medication for Opioid Use Disorder in Outpatient Care

Methadone for opioid use disorder has to come from an opioid treatment program. Federally that means a current certification under 42 CFR 8.11 and a DEA registration as a narcotic treatment program (21 CFR 1306.07(a)). On the Maryland side it means an Opioid Treatment Service written onto the BHA license, and a Level 1, 2.1, or 2.5 program can add one if the license specifically authorizes it (COMAR 10.63.02.02 and 10.63.03.19). Without that service, the practical step is a written coordination agreement with a specific certified OTP near your clients. SAMHSA’s Opioid Treatment Program Directory is the place to find one, and in our experience a surveyor gives a named partner more weight than a generic referral line. Buprenorphine is simpler. Section 1262 of the Consolidated Appropriations Act, 2023 removed the separate federal waiver, and DEA’s guidance to registrants is that a buprenorphine prescription now needs only a standard DEA registration number. SAMHSA states that naltrexone can be prescribed by any practitioner licensed to prescribe medications. Clients on medication are often the ones who benefit most from the added structure of Level 2.1 or 2.5, so build the medication workflow into your policies and your accreditation survey binder from day one. We also advise keeping naloxone on site with documented staff training.

Opening a Ketamine Practice Outside BHA Licensing in Maryland

Maryland has no ketamine clinic rule. The points below apply BHA’s licensing exemptions, the state’s ambulatory facility categories and the controlled substance rules to a stand-alone practice, and the conclusions are ours.

A stand-alone clinic usually stays outside BHA licensing. COMAR 10.63.01.03 requires a BHA license to provide community-based behavioral health services, but 10.63.01.04 exempts a health professional licensed under the Health Occupations Article who is in solo or group practice and practicing within the rules of the professional board. As we read it, a physician practice giving ketamine for depression sits inside that exemption. The picture changes if ketamine is folded into your BHA-licensed Level 1, 2.1 or 2.5 program, because then it rides on that program’s accreditation and policies.

We don’t see a separate facility license for the clinic either. COMAR 10.05.01.02 defines a freestanding ambulatory care facility as a surgical, endoscopy, major medical equipment, birthing or kidney dialysis facility, and an office giving ketamine or Spravato doesn’t match any of those.

Ownership and Management

Maryland’s ownership rule isn’t in any statute we could find. A 2019 unreported opinion of the Court of Special Appeals (Harris v. State) said Maryland “continues to follow” the common-law corporate practice of medicine doctrine, though the court’s own notice says the opinion can’t be cited as precedent. Given that uncertainty, we build the clinic as a practice owned by Maryland-licensed physicians, with a management services organization holding the lease, non-clinical staff and billing under a fixed-fee agreement and every clinical decision left with the physicians. Investors sit in the MSO, not the practice. The exemption’s text covers any health professional licensed under the Health Occupations Article, not only physicians, but whether a nurse-practitioner-led clinic works for your payers is a separate question, and a first-time NP needs a designated mentor for 18 months (COMAR 10.27.07.02).

Registrations and Monitoring

Get the OCSA Controlled Dangerous Substances registration for the clinic’s address first, since OCSA’s instructions put it ahead of the DEA application and require one for each location where CDS is administered or stored. DEA then registers that same address (21 CFR 1301.12). Spravato needs an outpatient setting certified in the REMS and at least 2 hours of monitoring after each dose. Maryland’s PDMP query mandate (Health-General § 21-2A-04.2) attaches to opioids and benzodiazepines, so ketamine alone doesn’t trigger it.

Run the BHA program and the clinic as two businesses, each with its own charts and its own drug supply, even when they share an address. If counselors in the outpatient program will send clients to a clinic their own physicians own, have counsel look at Maryland’s self-referral statute (Health Occupations § 1-302) and the federal Eliminating Kickbacks in Recovery Act (18 U.S.C. § 220) before the first referral. When the series starts inside a residential program, the ketamine section of Maryland Drug and Alcohol Inpatient Treatment Licensing covers that side.

Staffing an Outpatient Program

A small outpatient program typically needs a clinical director and two to three counselors, and the tiered credential structure is what actually keeps that affordable. The Maryland Board of Professional Counselors and Therapists credentials Maryland’s addiction counselors, from Alcohol and Drug Trainee through CSC-AD and CAC-AD to the graduate-level LGADC and the clinical-level LCADC. Maryland counselors earn a median of $59,530 a year statewide (BLS OEWS, May 2025), with the middle half between $50,030 and $73,220, so a clinical director plus two to three counselors commonly runs $210,000 to $290,000 a year in clinical payroll before benefits. Most Maryland outpatient programs aren’t paying that number in full, and the Board’s own supervision rule is why. COMAR 10.58.07.14 opens the supervisor role to a CAC-AD with two or more years on that certificate, provided the person also brings 3 years of documented alcohol and drug counseling (3,000 hours of it in direct client contact) and either supervision coursework, 18 CEUs of Board-approved supervision training, or a NAADAC or IC&RC clinical supervisor credential. A common approach staffs the program with CSC-AD and CAC-AD counselors under that supervisor at lower wages while they accumulate hours toward the next tier, with an LCADC as clinical director. An LGADC on the roster still draws on supervisor time. That license bars independent practice and supervising others (COMAR 10.58.07.04), and moving up to the LCADC takes 2 years and 2,000 hours of supervised clinical experience (10.58.07.05). Once your program model is set, the actual matrix and cost estimate follow from it.

COMAR 10.63 Is Being Rewritten

The first attempt, a partial proposal touching Chapters 01, 02, 06, and 09, ran in the Maryland Register on May 16, 2025, and the department pulled it on August 15, 2025. The second attempt is a full repeal and replacement. The Maryland Department of Health sent it to the AELR Committee on July 10, 2026, it was printed as a proposal in the August 21, 2026 Register, and public comment closed September 21, 2026. Under that draft, chapters 10.63.08 through 10.63.37 would each hold the rules for a specific program type. The department’s revisions page shows no adoption as of this writing, which leaves the current COMAR 10.63 text in place. Check with the licensing unit before you file in case that changes.

How to Submit Your BHA Application

Finish accreditation first. COMAR 10.63.06.03 asks for three accreditation documents with the application: the most recent survey report, any corrective action plan the accreditor required, and the final letter or certificate granting accreditation. A survey that is only scheduled does not produce that last item. Next, sign the Agreement to Cooperate with each local authority. Then file through BHA’s online application, which replaced the paper process effective February 10, 2025 (BHA’s COMAR 10.63 Online Application Guide walks through the screens). Under COMAR 10.63.06.02 the application names each service and each physical site and carries a copy of the signed agreement plus the local fire, safety, and health permits for every site. BHA’s January 2025 memo on the new system directs questions to bha.licensingcompliance@maryland.gov, and its April 17, 2026 alert says applications are reviewed in the order they are received.

What Delays Maryland Outpatient Applications

On the outpatient files we see, four mistakes explain most of the back-and-forth. The first is assuming outpatient care needs no accreditation. It does, and the survey can take longer than the build. The second is choosing an accreditor that is not approved for the levels on the application. The third is filing without agreements from every jurisdiction listed. The fourth is buying an expedite. BHA’s April 17, 2026 provider alert answers claims that a fee will speed up a license by saying it does not expedite applications based on recommendations or relationships, and it tells providers to be wary of anyone who makes “any guarantee or promise of licensure.”

Frequently Asked Questions

How long does it take to open an outpatient SUD program in Maryland?

Our planning range is roughly 9 to 15 months from first planning to a BHA license, and the accreditation survey drives most of it. We know of no processing time that BHA publishes. Its April 2026 alert says applications are reviewed in the order received and are not expedited on the strength of recommendations or relationships.

Does Maryland require accreditation for an outpatient SUD program?

Yes. Outpatient Level 1, intensive outpatient Level 2.1, and partial hospitalization Level 2.5 are accreditation-based licenses, so the program must be accredited by an organization approved by the Maryland Department of Health before BHA issues the license.

Is a Certificate of Need required for outpatient SUD treatment in Maryland?

No. The Maryland Health Care Commission has described its addiction treatment Certificate of Need reach as Level 3.7 intermediate care facilities and hospital-level Level 4 services, and since October 1, 2026 a Level 3.7 facility can file a 45-day written notice instead, provided the Commission finds the project meets the conditions in the new law. Nothing in that description or in the statute’s list of covered facilities reaches an outpatient Level 1, 2.1, or 2.5 program.

What is the Agreement to Cooperate?

It is a written agreement between your program and the Core Service Agency, Local Addictions Authority, or Local Behavioral Health Authority in each jurisdiction where you operate. BHA requires it with an initial application, a renewal, an added service, or a change of location or ownership.

Choosing an accreditor that covers the right outpatient levels in Maryland? Reach out here.

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