Maryland

Maryland

Maryland requires CONs within five broad categories—hospital beds, beds outside hospitals, equipment, facilities and services. Maryland maintains 32 independent CON requirements, and 18 specific exceptions. Maryland also maintains two moratoria, one of which prohibits general hospice services from acquiring homebased hospice services. Two of Maryland’s CON requirements are catch-all CONs. That is, if no other specific CON requirements apply, the catch-all CONs require hospitals to obtain a CON for any expenditure over $12.4 million and non-hospitals to obtain a CON for any expenditure above $6.2 million. Md. Code Regs. § 10.24.01.02(A)(5).

COVID-19 Response

As of May 15, 2020, Maryland had not suspended any CON requirements in response to COVID-19. Existing state regulations, however, provide for an emergency CON application process. Md. Code Regs. § 10.24.01.20 Under the emergency process, providers may request an emergency CON “[i]f a situation presents hazards to employees or patients of a healthcare facility or the closing of a facility by State licensing authorities requires changes or adjustments in other facilities to accommodate displaced patients[.]” Md. Code Regs. § 10.24.01.20(A). As of July 1, 2020, the Maryland Health Care Commission had approved 36 emergency CON applications.

Application Process

In Maryland, the CON application process takes up to 90 days if competitors do not request an evidentiary hearing or 150 days if competitors request a hearing. Md. Code Regs. § 10.24.01.09(E)(1). Applications can be submitted at any time, and, although the statute allows the establishment of an application fee through regulation, no such fee has been established. Md. Code Regs., Health-Gen. § 19-120(b). Competitors can intervene in the application process and can offer evidence or argument as to why an application should be denied. Md. Code Regs. § 10.24.01.09(E)(6)(b).

CON? Number of CONs Moratoria Temporary COVID-19 response:
Hospital Beds Yes 2 – Preexisting regulations
Beds Outside Hospitals Yes 5 – Preexisting regulations
Equipment Yes 1 – Preexisting regulations
Facilities/ Buildings Yes 10 1 Preexisting regulations
Services Yes 14 1 Preexisting regulations
Emergency Medical Transport No – – –

Note: these citations are accurate as of May 2020.

Maryland CONs in Detail

Category  

Moratoria/Types of CONs

Md. Code Regs.

Hospital Beds  

1.Hospital beds.

§§ 10.24.01.02(A)(3),

10.24.01.01(12)(a)(i)

2.Beds in limited service hospitals. 

§§ 10.24.01.02(A)(3),

10.24.01.01(12)(a)(ii) 

Beds Outside Hospitals  

1.Beds in “related institutions.” 

§§ 10.24.01.02(A)(3),

10.24.01.01(12)(a)(iii) 

2.Beds in ambulatory surgical facilities.

 §§ 10.24.01.02(A)(3), 

10.24.01.01(12)(a)(iv) 

3.Beds in rehabilitation facilities.

 §§ 10.24.01.02(A)(3),

10.24.01.01(12)(a)(v) 

4.Beds in home health agencies. 

 §§ 10.24.01.02(A)(3),

10.24.01.01(12)(a)(vi) 

5.Beds in hospice facilities. 

 §§ 10.24.01.02(A)(3),

10.24.01.01(12)(a)(vii) 

Equipment  

1.A capital expenditure made as part of a replacement of any equipment at a hospital in excess of $12.4 million, as updated annually.

Md. Code Health § 19-120(k)(1)(i)(2);

see Md. Health Care Comm’n, Threshold for Reviewability of Health Care Facility Capital Expenditures (2019);44

Md. Code Regs. § 10.24.01.02(A)(5)

Facilities/Buildings 

1.Moratorium on a licensed general hospital located in Kent County converting to a freestanding medical facility prior to July 1, 2020.

Md. Code Health § 19-120(o)(3)(iii)

Establishment of one of the following facilities:

1.Hospitals. 

§§ 10.24.01.02(A)(1), 

10.24.01.01(12)(a)(i) 

2.Limited service hospitals. 

§ 10.24.01.01(12)(a)(ii) 

3.“Related institution” as defined in Md. Code Regs., Health-Gen. § 19-301(o). 

§ 10.24.01.01(12)(a)(iii)

4.Ambulatory surgical facilities. 

§ 10.24.01.01(12)(a)(iv) 

5.Rehabilitation facilities. 

§ 10.24.01.01(12)(a)(v) 

6.Hospice.

§ 10.24.01.01(12)(a)(vii) 

7.Existing health care facility moved to another site.

 § 10.24.01.02(A)(2)(a-c) 

8.Change of service that establishes a new freestanding surgical facility. 

 § 10.24.01.02(A)(4)(c) 

9.Builds or expands ambulatory surgical capacity in any setting owned or controlled by a hospital, if the building or expansion would increase the surgical capacity of the State’s health care system. 

 § 10.24.01.02(A)(4)(d) 

Category  

Moratoria/Types of CONs

Md. Code Regs.

Facilities/Buildings

10.Closing an existing health care facility or converting it to a non-health related use, except for closure of an acute general hospital or the temporary delicensure of a health care facility. 

§ 10.24.01.02(A)(4)(g) 

Services

1.Moratorium prohibiting the Commission from granting a CON with respect to an acquisition that authorizes a general hospice to provide home-based hospice services on a statewide basis. 

Md. Code Health § 19-120(n)

1.Changing service that establishes a new medical service.

§ 10.24.01.02(A)(4)(a)

2.Changing service that establishes new open-heart surgery program. 

3.Changing service that establishes new organ transplant surgery program. 

4.Changing service that establishes new burn treatment program. 

5.Changing service that establishes new neonatal intensive care program. 

§ 10.24.01.02(A)(4)(b) 

6.Changing service that establishes new home health agency. 

7.Changing service that establishes new hospice program. 

§ 10.24.01.02(A)(4)(c)   

8.Establishing a new home health agency.

§ 10.24.01.01(12)(a)(vi)

9.Establishing a new subunit by an existing home health agency. 

§ 10.24.01.02(A)(4)(e)(i)

10.The expansion of a home health agency into a jurisdiction not included in a previous CON.

§ 10.24.01.02(A)(4)(e)(ii) 

11.Transferring ownership of a subunit or a facility- based home health care service of an existing health care facility that separates the ownership of the subunit from the home health agency or home health care service that established the subunit. 

§ 10.24.01.02(A)(4)(e)(iii) 

12.Closing an existing medical service, unless an exemption applies. 

§ 10.24.01.02(A)(4)(f) 

13.Any capital expenditure in excess of $12.4 million for hospitals.

14.Any capital expenditure in excess of and $6.2 million for non-hospital facilities. 

§ 10.24.01.02(A)(5);

see Threshold for Reviewability of Health Care Facility Capital Expenditures

Emergency Medical Transport  

  No CONs in this category.

  

Maryland CON Exceptions

No CON Required For:   

Md. Code Regs.

1.The acquisition of an existing health care facility, where the Commission receives notice and determines that the health care services and bed capacity will not change.  

§ 10.24.01.03(A)(3) 

2.Closure of an acute general hospital, as long as notice is provided and other requirements are met.  

§ 10.24.01.03(B)  

3.Temporary delicensure of bed capacity of health care facility. 

§ 10.24.01.03(C)  

4.Relocating an existing health care facility owned or controlled by a merged asset system, if notice is provided and the change does not change the health care services offered or require capital expenditure exceeding the threshold.

§ 10.24.01.03(D)  

5.A change in bed capacity that does not exceed ten beds or 10% in certain facilities. 

§ 10.24.01.03(E)  

6.A project of a health maintenance organization where the project will be used only by the subscribers of that organization. 

§ 10.24.01.03(F)  

7.A home health agency opening a branch office. 

§ 10.24.01.03(G) 

8.Religious orders. 

§ 10.24.01.03(H) 

9.Capital expenditures for site acquisitions, acquisition of a health care facility where §A is satisfied; for business or office equipment unrelated to patient care; acquisition and installation of major medical equipment. 

§ 10.24.01.03(I)(2)  

10.Capital expenditure by a hospital or nursing home, for equipment, construction or renovation that is not directly related to patient care or a change in patient charges. 

§ 10.24.01.03(I)(3) 

11.A CON is not required by a hospital before it obligates an amount exceeding the review threshold for capital expenditure for physical plant construction or renovation, or before it receives a donated physical plant whose appraised value exceeds the review threshold under § 10.24.01.03(J)(a)-(c). 

§ 10.24.01.03(J) 

12.Merger or consolidation of two or more hospitals. 

§ 10.24.01.04(A)(1) 

13.Relocation of an existing health care facility owned or controlled by a merged asset system. 

§ 10.24.01.04(A)(2) 

14.Change in bed capacity of an existing facility pursuant to the consolidation or merger of two or more facilities. 

§ 10.24.01.04(A)(3) 

15.Change in type or scope of services offered by a facility if the Commission finds that the proposed change is pursuant to a consolidation or merger of two facilities, conversion to a non-health related use or conversion to a limited service hospital. 

§ 10.24.01.04(A)(4) 

16.Capital expenditure exceeding the threshold due to a merger or consolidation of health care facilities, or conversion of a facility to a non-health-related use.

§ 10.24.01.04(A)(5) 

17.The closure of an acute general hospital or part of a hospital, in a jurisdiction with fewer than three acute general hospitals. 

§ 10.24.01.04(A)(6) 

18.Freestanding medical facility pilot project or is established as the result of the conversation of a licensed general hospital.

Md. Code Health

§ 19-120(o)(2)

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