Maryland home health vs home care: RSA, referral agency or home health agency

The statute keeps them apart. Licensed home health agencies (and anyone required to be one), hospices, hospitals, related institutions, Medicaid Personal Care Program providers, licensed practitioners practising their own occupation, nursing referral service agencies, single-profession practices and approved residential rehabilitation providers are not RSAs. HG §19-4A-01(f)(3) OHCQ’s 2020 slides said an RSA is not a home health agency: home health agencies provide a higher level of care, are held to more stringent regulations, and participate in Medicare and with health insurers. OHCQ slides (2020), slide 17

What an RSA can do. Eleven services count as home health care, among them home health aide, nursing, the therapies, drug services, medical social services and home medical equipment, and one is enough to need the license. HG §19-4A-01(b) OHCQ says some RSAs have nurses giving skilled care and certified caregivers helping with activities of daily living such as bathing, grooming and dressing, for as many hours as needed, up to 24/7. OHCQ, RSA page OHCQ’s 2020 slides described two types of RSA: "Skilled Nursing with Aides" (Levels 1 to 3) and "RSA Others", such as DME and therapy agencies, and said nurses could provide care without aides under an RSA Others license. OHCQ slides (2020)

What the RSA’s registered nurse does is in the registered nurse in a Maryland RSA, and where aides stop with medication in medication in a Maryland RSA.

CareRulebook’s manual sets out the services you offer and how you coordinate with a home health agency or other provider in Policy 2.1, and when a client needs skilled services in Policy 4.1. The delineation of services when you coordinate care with another provider is one of the 23 policy items. COMAR 10.07.05.08B(1)(a)(ii)

"An agency that provides only household or family support services as defined in Regulation .02B(14) of this chapter does not require licensure." COMAR 10.07.05.03B Household or family support means tasks that supplement a person’s instrumental activities of daily living, or child care for children who need no medical attention. .02B(14) Those activities are light housekeeping and home management; meal planning and preparation; shopping and errands. .02B(17)

Companionship. Companionship is not one of the eleven home health care services in the statute, and the RSA rules do not name it. When the 2012 rules were adopted, OHCQ said they allow companion and other non-health-related services without nursing oversight (said of care within licensed agencies). By our reading, companion and homemaker work with no hands-on help needs no RSA license; help with bathing, dressing, toileting or transfers does. Confirm with OHCQ. OHCQ, 2012 (archived) Note that the nursing referral statute does list companionship among the help a referred care provider gives. HG §19-4B-01(c) By our reading, that matters only to a business that refers companions rather than employing them.

Once you are licensed. The record for a client "assessed as not requiring certified caregivers or skilled services" still includes a nursing assessment and plan of care. COMAR 10.07.05.14B By our reading, an RSA that also offers household help brings those clients under its nurse too. Ask OHCQ how it reads this.

A nursing referral service agency (NRSA) screens and refers licensed professionals or care providers to clients at the client’s request. It is a separate license (Health-General 19-4B, COMAR 10.07.07); OHCQ’s NRSA list of October 2, 2026 has 391 rows (counted by us). HG §19-4B-01(h)

• Referral must be the whole business. An NRSA is outside the RSA definition only if screening or referring for the client’s selection is its sole business and it does not itself provide any home health care service. An agency that employs and sends its own caregivers is an RSA. COMAR 10.07.05.02B(25)(b)(vi)
• Its duties are narrow. COMAR 10.07.07 asks an NRSA for screening policies and procedures, a complaint process and client choice; it has no care plan, nursing supervision or 23-item policy list. COMAR 10.07.07.08B An NRSA tells the client or representative whether or not it has decided that the referral suits the client’s needs and complies with the Health Occupations Article. .08B(2)
• Applying. OHCQ says an NRSA applies with written policies and procedures, workers’ compensation proof and an SDAT letter of good standing, and a license generally takes 1-2 months after a complete application. OHCQ, NRSA page
• The fee. COMAR 10.07.07.04 still lists a nonrefundable $1,000 fee for a 3-year NRSA license and for renewal, with the policies filed with the application. The 2018 fiscal note lists nurse referral agencies with RSAs among the providers whose fees were eliminated. We have not saved OHCQ’s NRSA application, so we cannot say what it charges now. COMAR 10.07.07.04A(3) Fiscal note, Appendix 2
• Inspections. An NRSA sends a written plan of correction within 10 business days of a notice of deficiencies (an RSA has 10 calendar days). COMAR 10.07.07.07C

CareRulebook’s manual is written for an RSA, not a nursing referral agency.

OHCQ used to sort nursing-and-aide RSAs into Level 1 (RN supervision of aides giving personal care without medication management), Level 2 (with medication management) and Level 3 (complex care). The current application no longer asks for a level, but Medicaid’s Community First Choice rule still refers to Levels Two and Three. OHCQ slides (2020), slide 15 In 2020 OHCQ said Level 1 personal care was given under the client’s contract, and Level 2 (medication administration) and Level 3 (complex care such as large wounds, IV therapy and ventilator care) under physician orders. Slide 44

Today’s application asks only which of ten services you will provide. Application, Section B But Medicaid’s rule still says a personal assistance provider must "be licensed as a Residential Service Agency under COMAR 10.07.05 to provide Level Two or Level Three home care services". COMAR 10.09.84.06A(1)

By our reading, the old levels line up with the RN supervision intervals in the rule today: on-site supervision at least every 4 months when staff neither give nor help with medication, every 3 months when they help with self-administration, and every 45 days when they give medication. COMAR 10.07.05.12E(2) How OHCQ records an agency’s level now, and whether an aide-only agency needs one to enroll with Medicaid, is on our list of questions for OHCQ.

A license does not by itself mean anyone will pay you: "licensure under this subtitle does not entitle a residential service agency to reimbursement by a third party payor", except as federal law provides. HG §19-4A-10(a) OHCQ says RSAs can bill Medicaid, private insurance and private pay, but not Medicare unless they are a DME provider. OHCQ inservice (2026), slide 11

• Employees only. "The Department may reimburse a residential service agency for personal assistance services only if the personal assistance services are provided by an individual classified as an employee." HG §19-4A-10(b) Chapter 881 of 2024 (Homecare Worker Rights Act) took effect January 1, 2026 (moved from October 1, 2025 by amendment). Chapter 881 of 2024
• Community First Choice providers. Community First Choice personal assistance providers must be RSAs licensed to provide Level Two or Level Three home care services, employ an RN to assess participants and delegate tasks, run State criminal history checks on all direct service workers, and collect monthly signed service verifications. COMAR 10.09.84.06A Under Community First Choice, a worker giving delegated nursing services must be a certified medication technician to administer medications, and a certified nursing assistant for other delegated nursing functions. .06B
• Participant direction. Community First Choice providers let participants direct their services and exercise as much control as they want over selecting, training, scheduling, assigning duties to and dismissing their worker. .06A(4) A personal assistance provider agency may not assign the participant’s representative to provide services to that participant. .06C
• The yearly report. By October 1 each year, an RSA paid by Medicaid for personal care aide services reports how many aides it classifies as employees and as independent contractors. HG §19-4A-11(c)
• When to apply. OHCQ’s 2020 slides said an agency needed a regular license, not a provisional one, to apply for Medicaid reimbursement. Old guidance, not confirmed for 2026. OHCQ slides (2020), slide 56

Providers under the Medical Assistance Personal Care Program are outside the RSA definition. HG §19-4A-01(f)(3) We have not reviewed Medicaid enrollment in full; this section is context for choosing a license. Worker classification for private-pay agencies is covered on the Maryland guide.

OHCQ: "you must first apply for a Certificate of Need (CON) from the Maryland Health Care Commission (MHCC)." OHCQ, Home Health Agencies OHCQ points applicants to the Commission (410-764-3460) for the process. OHCQ handles home health agencies’ initial licensure, recertification surveys and complaint investigations, under COMAR 10.07.10. same

For an RSA, the statute says the applicant "May not be required to meet the requirements of Subtitle 1 of this title for certificate of need". HG §19-4A-05(3)

We have not saved the Commission’s Certificate of Need guidance or the home health chapter of its State Health Plan (COMAR 10.24.16), so this page does not cover how a Certificate of Need is decided. If your plan is home health, start with the Commission.