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: BHA moved license applications to an online process effective February 10, 2025. Start at BHA Licensing and Certification | Questions about the online application: bha.licensingcompliance@maryland.gov
Residential substance use disorder treatment in Maryland is licensed by the Maryland Department of Health, Behavioral Health Administration (BHA) under COMAR 10.63, and the license is built on accreditation. Most operators assume they will get a license and then pursue accreditation. Maryland reverses that order, and it changes how you plan the first year.
Accreditation Comes First and the License Follows It
Most states license first and leave accreditation as a later, optional step. Maryland flips that sequence entirely. Maryland calls it an accreditation-based license, and the term is a legal one. COMAR 10.63.02.02 puts all four residential levels, 3.1 through 3.7, on the accreditation-based list, so BHA will not license a residential program until it holds accreditation from an organization the Maryland Department of Health has approved. For a community residential program the choice is ACHC, CARF, the Council on Accreditation, and The Joint Commission. The fifth approved body, the National Commission on Correctional Health Care, is limited to correctional facilities. BHA publishes a crosswalk for each accreditor showing which Maryland program types it can cover, and its own accreditation-based licensing page warns that not every accreditor is approved for every program type. Check the crosswalk before you sign an accreditation contract.
After licensure, COMAR 10.63.01.05 lets the Department or its designees make announced or unannounced visits to investigate a complaint, and to inspect and copy financial, treatment, and service records. Separately, 10.63.02.03 allows an inspection of an accredited program when significant concerns are raised about how it operates or about the body that accredited it. Day to day, the routine survey work sits with your accreditor. Under COMAR 10.63.06.05 the license term equals your accreditation period plus 3 months, and the renewal application has to reach the Department at least 60 days before the current license expires. Because the license rides on accreditation, a lapse puts it at risk.
The Levels Maryland Licenses, and Where a Certificate of Need Applies
| Residential Level | COMAR 10.63 Section | Certificate of Need | Accreditation-Based License |
|---|---|---|---|
| Level 3.1, low intensity | 10.63.03.11 | Not required | Yes |
| Level 3.3, medium intensity | 10.63.03.12 | Not required | Yes |
| Level 3.5, high intensity | 10.63.03.13 | Not required | Yes |
| Level 3.7, residential intensive (intermediate care facility) | 10.63.03.14 | MHCC Certificate of Need, or since October 1, 2026, an MHCC-approved 45-day notice exemption | Yes |
| Withdrawal management at 3.2-WM or 3.7-WM, added as a service | 10.63.03.18 | No separate MHCC step found for 3.2-WM; MHCC has reviewed 3.7-WM beds together with Level 3.7 | Only when the license specifically authorizes it (10.63.02.02) |
Because BHA licenses residential programs by ASAM level, CARF’s ASAM Level of Care Certification works here as an added, independent check rather than a substitute for anything in the table. CARF delivers it in partnership with ASAM for adult Levels 3.1, 3.5 and 3.7 (Level 3.3 isn’t offered), and it is a separate route from the accreditation behind your license. The certification itself may not appear on the BHA license, but insurers can confirm it through CARF’s provider search.
MHCC Review Applies Only at Level 3.7
The Maryland Health Care Commission (MHCC) plans for alcohol and drug intermediate care through the State Health Plan chapter incorporated at COMAR 10.24.14. In its 2022 Pyramid Walden decision before this fall, MHCC put the reach of Certificate of Need this way: a CON was needed to establish or relocate an intermediate care facility (ASAM Level 3.7, with 3.7-WM beds reviewed alongside it) or to establish, relocate, or add beds to a hospital-level Level 4 service. In a 2022 case, the Level 3.5 beds planned for the same building needed no CON at all. We have found nothing in MHCC material that reaches outpatient care or residential Levels 3.1 through 3.5.
The Level 3.7 gate changed on October 1, 2026, when Chapters 68 and 69 of 2026 (Senate Bill 444 and House Bill 498, both signed April 14, 2026) took effect. A facility offering medically managed residential SUD treatment at Level 3.7 can now open, or change its bed count, without a full CON review if it files written notice with MHCC at least 45 days ahead and the Commission finds the project is not inconsistent with the State Health Plan, will produce more efficient and effective care, and is in the public interest. The same law repealed the old exemption that let a licensed intermediate care facility change bed capacity with no review, so adding beds later now runs through that notice and those findings too. For a sense of scale under the old process, MHCC issued a CON in 2023 for a 16-bed Level 3.7 and 3.7-WM facility, and a 2022 recommended decision covered 50 adult intermediate care beds. Whichever route you take with MHCC, it is not a license, so BHA licensure and accreditation still follow.
The Agreement to Cooperate Is a Separate Local Step
Most guides treat this as a formality, but it’s a genuine separate approval with its own paperwork and timeline. COMAR 10.63.01.05 says the agreement comes before you even apply: you sign an Agreement to Cooperate with the Core Service Agency, Local Addictions Authority, or Local Behavioral Health Authority operating in each county, or Baltimore City, where you will run services. BHA’s form (DHMH #4781, revised July 31, 2025) calls for one with an initial application, a renewal, an added service, and any requested change to the license. The local authority acts as BHA’s designee and collects your supporting documents as part of signing. Start these conversations while accreditation is still underway, since the local office is a separate calendar from BHA and from your accreditor.
Medication for Opioid Use Disorder in a Residential Setting
Maryland licenses residential programs by ASAM level, and whatever level yours holds, a real medication pathway belongs in the clinical plan, not a line that just says referrals happen when needed. Section 1262 of the Consolidated Appropriations Act, 2023 ended the federal waiver for buprenorphine, and DEA has told registrants that a buprenorphine prescription now needs only a standard DEA registration number, so you no longer have to recruit a specially waivered prescriber. Methadone for addiction is different. It comes from an opioid treatment program holding federal certification under 42 CFR Part 8 plus its own DEA registration, and 21 CFR 1306.07 leaves other practitioners only slim exceptions, such as a one-time supply of no more than three days while a referral is arranged. Maryland also lists Opioid Treatment Service as its own program type (COMAR 10.63.03.19). A residential program without that service needs a working arrangement with an OTP that covers transport and dose continuity, and a named partner reads better to a surveyor than a generic promise. Our own practice is to keep naloxone on site at every level.
Level 3.7 is the natural home for on-site induction. COMAR 10.63.03.14 already requires a physician, nurse practitioner, or physician assistant who sees each patient in person within 24 hours of admission and is available for on-site monitoring every day. At Levels 3.1 through 3.5 we usually set up a prescriber relationship for continuation instead. Expect your accreditor’s surveyors to check, under their medication management standards, whether these arrangements hold up in practice.
Where Ketamine Fits Under a Maryland Residential License
COMAR 10.63 never mentions ketamine. This section reads the program rules, Maryland’s controlled substance registration and the federal DEA rules together, so wherever we say a step is or isn’t needed, treat it as our reading to confirm with BHA and your accreditor.
Only one residential level in Maryland already writes a prescriber into the rule. At Level 3.7, COMAR 10.63.03.14 requires a physician, nurse practitioner, or physician assistant who assesses each patient in person within 24 hours of admission and is available for on-site monitoring every day. The Level 3.5 regulation (10.63.03.13) sets no medical staffing requirement at all. In our planning, a 3.7 program can run a ketamine series in house, while a 3.5 program sends the resident to an outside prescriber who has the monitoring staff and equipment to handle it.
Ketamine doesn’t turn into a new program type either. COMAR 10.63.06.07 asks for prior approval when you add, close or move a site, and for accreditation evidence and local notice when you add a program type. A medication protocol inside an existing 3.7 program is neither one, as we read the rule. The license stands on accreditation, though, so the protocol belongs in the policies your accreditor surveys, and we would tell the accreditor and send BHA’s licensing unit a short written description before the first dose.
State and Federal Registrations
Maryland puts a state registration ahead of the federal one. The Office of Controlled Substances Administration (OCSA) requires a Maryland Controlled Dangerous Substances (CDS) registration for each location where CDS is administered, stored or dispensed, and its instructions tell practitioners to get it before applying for a DEA number. Ketamine is a Schedule III drug (21 CFR 1308.13(c)(7)), and 21 CFR 1301.12 calls for a separate DEA registration at each place where controlled substances are dispensed, exempting only an office where a practitioner prescribes, administers nothing and keeps no supply. A 3.7 facility stocking ketamine needs both registrations for its own address.
The PDMP piece is narrower than people expect. Maryland’s prescriber query rule (Health-General § 21-2A-04.2) is triggered by starting a course of an opioid or a benzodiazepine, so ketamine by itself doesn’t set it off, though a resident starting buprenorphine still does. Esketamine (Spravato) carries its own REMS conditions: the treatment setting must be certified, a healthcare provider monitors the patient for at least 2 hours after each dose, and the drug is never dispensed for home use.
We found no Maryland Board of Nursing position on registered nurses administering ketamine, so the written order, the monitoring plan and each nurse’s documented competency are what a surveyor will look at. A nurse practitioner certified for the first time also works with a designated mentor, a physician or NP with at least three years of clinical experience, for 18 months (COMAR 10.27.07.01 and .02).
Who Gets Offered It
Our screening starts with the diagnosis that isn’t the addiction. Withdrawal has to be finished, the depression or PTSD has to have held out against standard treatment, and any past misuse of ketamine or another dissociative takes a resident off the list. A resident on buprenorphine or methadone stays on it, with ketamine added on top rather than swapped in.
Handing the Series to an Outpatient Practice
A residential stay gives a resident a monitored place to start, but most series outlast the stay, so we name the outpatient practice that will continue the doses at admission rather than at discharge. That practice is easier to set up than the residential program. COMAR 10.63.01.04 exempts a health professional licensed under the Health Occupations Article, in solo or group practice, from BHA licensing, and the same regulation says the exemption never reaches residential SUD programs under 10.63.03.11 through .14. Ownership is less settled. In a 2019 unreported opinion (Harris v. State), the Court of Special Appeals wrote that Maryland “continues to follow” the common-law corporate practice of medicine doctrine. Unreported opinions can’t be cited as precedent, and we found no statute that answers the question, so we set these clinics up as physician-owned practices with a management services organization running the business side. The ketamine section of Maryland Drug and Alcohol Outpatient Treatment Licensing covers that structure.
Money and referrals between the program and the clinic need a lawyer’s review in both directions. The federal Eliminating Kickbacks in Recovery Act (18 U.S.C. § 220) makes it a crime to pay or receive anything of value for referring patients to a licensed clinical treatment facility. Maryland’s self-referral statute, Health Occupations § 1-302, also bars a practitioner from referring a patient to a health care entity in which the practitioner, alone or together with immediate family, owns a beneficial interest. A medical director who owns part of the clinic sits squarely in that position, so the referral needs to fit one of the exceptions in subsection (d) of that section.
Staffing a Residential Program
Maryland’s counselor supervision rules are where the real staffing flexibility lives. We build residential programs around a clinical director, usually a Licensed Clinical Alcohol and Drug Counselor (LCADC), plus enough credentialed staff to match your population’s acuity. The Maryland Board of Professional Counselors and Therapists issues the addiction credentials, from Alcohol and Drug Trainee through Certified Supervised Counselor (CSC-AD), Certified Associate Counselor (CAC-AD), and Licensed Graduate Alcohol and Drug Counselor (LGADC) up to the LCADC.
Round-the-clock coverage adds real cost. Maryland counselors earn a median of $59,530 statewide (BLS OEWS, May 2025), just above the $59,350 national median, with the middle half earning between $50,030 and $73,220, so a residential program with a clinical director, several counselors, and 24-hour direct-care staff commonly runs past $400,000 a year in payroll before nursing coverage. It’s a real figure, and Maryland’s supervision rules give operators a genuine way to bring it down. Under COMAR 10.58.07.14, Board-approved supervisors are not limited to LCADCs. A CAC-AD who has held that certificate for at least 2 years can qualify too, provided the supervisor has 3 years of documented alcohol and drug counseling, 3,000 hours of it in direct client contact, and has completed supervision coursework, 18 CEUs of approved supervision training, or a recognized clinical supervisor credential. Trainees, CSC-AD and CAC-AD counselors, and LGADCs all practice under an approved supervisor (10.58.07.13). One way to bring payroll down is to staff a large share of counseling roles with trainees and CSC-AD counselors building their hours under one approved supervisor at reduced wages, keep an LCADC as clinical director, and pair an RN with several LPNs for medical oversight rather than staffing every shift with a registered nurse. Graduate-level hires take their own planning. An LGADC may not practice independently or supervise anyone (COMAR 10.58.07.04), and needs 2 years and 2,000 hours of supervised clinical experience before qualifying for the LCADC (10.58.07.05), so budget supervisor time for them as well. The actual matrix follows once census and level of care are confirmed.
COMAR 10.63 Is Being Rewritten
The ground is actively shifting under this regulation, so don’t treat today’s text as permanent. The rewrite has already had one false start. A proposal covering Chapters 01, 02, 06, and 09 appeared in the May 16, 2025 Maryland Register, and the department withdrew it that August. A full replacement went to the legislature’s AELR Committee on July 10, 2026 and ran as a proposed rule in the August 21, 2026 Maryland Register, with comments taken through September 21, 2026. As of early October 2026 the department’s revisions page lists no adoption, so ask BHA which text governs your application on the day you file.
How to Submit Your BHA Application
BHA handles initial applications, and the order of steps matters. Start with accreditation, and finish it. COMAR 10.63.06.03 has you attach the accreditor’s final letter or certificate granting accreditation, along with your latest survey report and any corrective action plan the accreditor required, so having a survey date on the calendar isn’t enough to file. Next, sign the Agreement to Cooperate with each local authority. Then file through BHA’s online application, which took the place of the paper process effective February 10, 2025. COMAR 10.63.06.02 has the application name every service and every physical site, and include a copy of the signed agreement along with local fire, safety, and health permits for each site. For questions about the online system, BHA’s launch memo pointed providers to bha.licensingcompliance@maryland.gov. BHA says applications are reviewed in the order they are received.
What Delays Maryland Residential Applications
In our experience, four issues cause most of the delays on Maryland residential files. The most common delay is treating accreditation as a parallel workstream when BHA treats it as the entry ticket. The second is a missing or unsigned Agreement to Cooperate for one of the jurisdictions on the application. The third is paying for a promise to speed things up. In an April 17, 2026 provider alert, BHA called offers to expedite an application in exchange for money misinformation, said applications are reviewed in the order they are received, and urged providers to be cautious about consultants who make “any guarantee or promise of licensure.” The fourth is assuming MHCC review reaches Levels 3.1 through 3.5, or forgetting that a 3.7 build still needs either a CON or the 45-day notice exemption.
Frequently Asked Questions
How long does it take to open a residential SUD program in Maryland?
In our experience, Levels 3.1 through 3.5 take roughly 12 to 18 months, mostly because the accreditation survey has to be finished before BHA will license the program. A Level 3.7 build adds Maryland Health Care Commission review on top of that, and the shortest MHCC path, the notice exemption available since October 1, 2026, still takes at least 45 days. We have not found a published BHA processing time, and BHA says it does not expedite applications.
Does a Maryland residential SUD program need a Certificate of Need?
Only at Level 3.7, which Maryland treats as an alcoholism and drug abuse intermediate care facility, and at the hospital level. Since October 1, 2026, a Level 3.7 facility can avoid a full CON by giving MHCC written notice at least 45 days ahead and receiving the Commission’s favorable findings. We have found no MHCC review that applies to Levels 3.1, 3.3, or 3.5.
Which accreditors does Maryland accept for a residential license?
For community programs, the Maryland Department of Health currently approves ACHC, CARF, the Council on Accreditation, and The Joint Commission, and BHA publishes a crosswalk for each one showing which program types it can cover. A fifth accreditor, the National Commission on Correctional Health Care, is approved for correctional facilities only.
Can I pay someone to speed up my BHA application?
No. BHA said in an April 2026 provider alert that it does not expedite applications, that it reviews them in the order received, and that offers to speed up a license for a fee are misinformation.
Sequencing accreditation and the Agreement to Cooperate for a Maryland residential program? Reach out here.
Sources
- COMAR 10.63.01.05: Requirements for Licensed Community-Based Behavioral Health Program (checked October 7, 2026)
- COMAR 10.63.02.01 and .02: Covered Programs and Services (checked October 7, 2026)
- COMAR 10.63.02.03: Requirements for a Program with an Accreditation-Based License (checked October 7, 2026)
- COMAR 10.63.03: Program Descriptions, including Levels 3.1 to 3.7 and Withdrawal Management (checked October 7, 2026)
- COMAR 10.63.03.14: Residential-Intensive Level 3.7 Program (checked October 7, 2026)
- COMAR 10.63.03.18: Withdrawal Management Service (checked October 7, 2026)
- COMAR 10.63.06.02: License Application Process (checked October 7, 2026)
- COMAR 10.63.06.03: Additional Application Requirements for Licenses Requiring Accreditation (checked October 7, 2026)
- COMAR 10.63.06.05: Issuance and Duration of Licenses (checked October 7, 2026)
- Maryland Department of Health: COMAR 10.63 Regulatory Revisions (checked October 7, 2026)
- BHA: Accreditation Based Licensing (checked October 7, 2026)
- BHA: Updated Licensing Application for Community Behavioral Health Providers, January 2025 (checked October 7, 2026)
- BHA: Licensing and Certification (checked October 7, 2026)
- BHA: Alert Regarding Licensing Misinformation, April 17, 2026 (checked October 7, 2026)
- BHA: Agreement to Cooperate form, DHMH #4781, revised July 31, 2025 (checked October 7, 2026)
- Maryland General Assembly, Chapter 69 of 2026 (HB 498): Certificate of Need, Intermediate Health Care Facilities (checked October 7, 2026)
- Maryland General Assembly, Chapter 68 of 2026 (SB 444): Certificate of Need, Intermediate Health Care Facilities (checked October 7, 2026)
- Department of Legislative Services: Fiscal and Policy Note, HB 498 (2026) (checked October 7, 2026)
- COMAR 10.24.14.01: State Health Plan, Alcoholism and Drug Abuse Intermediate Care Facility Treatment Services (checked October 7, 2026)
- MHCC: Recommended Decision, Pyramid Walden (2022) (checked October 7, 2026)
- MHCC: Certificate of Need, Hygea Detox at Camp Meade (2023) (checked October 7, 2026)
- COMAR 10.58.07: Alcohol and Drug Counselors, including .04, .05, .13, and .14 (checked October 7, 2026)
- SAMHSA: Waiver Elimination (MAT Act) (checked October 7, 2026)
- DEA Diversion Control Division: Dear Registrant Letter on the DATA-Waiver (checked October 7, 2026)
- eCFR, 42 CFR 8.2 and 8.11: Definitions and Opioid treatment program certification (checked October 7, 2026)
- 21 CFR 1306.07 (Cornell LII mirror of the official text): Administering or dispensing of narcotic drugs (checked October 7, 2026)
- CARF International: ASAM Level of Care Certification and Find a Provider (checked October 7, 2026)
- American Society of Addiction Medicine: Level of Care Certification (checked October 7, 2026)
- COMAR 10.63.01.04, via Justia: Exempt providers, including solo and group practice (checked October 9, 2026)
- COMAR 10.63.03.13, via Justia: Residential High-Intensity Level 3.5 Program (checked October 9, 2026)
- COMAR 10.63.06.07, via Justia: License modification (checked October 9, 2026)
- COMAR 10.27.07.01 and .02, via Justia: Nurse practitioner definitions and certification and designated mentor (checked October 9, 2026)
- Maryland OCSA: Practitioner CDS registration instructions (checked October 9, 2026)
- Health-General § 21-2A-04.2, text posted by the Maryland Department of Health PDMP: Prescription monitoring by prescribers (use mandate), as amended by HB 517, Chapter 772 of 2018 (checked October 9, 2026)
- 21 CFR 1308.13 and 1301.12 (Cornell LII mirror of the official text): Schedule III, ketamine and Separate registrations for separate locations (checked October 9, 2026)
- SPRAVATO REMS: Program requirements for healthcare settings (checked October 9, 2026)
- Maryland Court of Special Appeals: Harris v. State, No. 745, Sept. Term 2018 (unreported, 2019) (checked October 9, 2026)
- Maryland Code, Health Occupations § 1-302: Prohibited self-referrals and exceptions (checked October 9, 2026)
- 18 U.S.C. § 220 (Cornell LII mirror of the official text): Illegal remunerations for referrals to recovery homes, clinical treatment facilities, and laboratories (checked October 9, 2026)
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