Maryland
Certificate of Need Analysis
CON Score
95/100
Highly Restrictive
Governor
Wes Moore
Democrat
CON Rank
Top 5/19
Most Restrictive States
1968
Year Enacted
100%
Hospital System Affiliation
61.5%
Top Insurer Market Share
90
Day Standard Review
Scope of Regulation
What requires a Certificate of Need in Maryland?
Covered Services & Facilities
- ●New or expanded hospitals
- ●Ambulatory surgical facilities (2+ ORs)
- ●Nursing homes & residential treatment centers
- ●Home health and hospice agencies
- ●Specialized services (organ transplant, open-heart surgery, NICUs)
- ●Capital expenditures over inflation-adjusted thresholds ($10M for hospitals, $5M for others)
Application Process
| Review Authority | Maryland Health Care Commission (MHCC) |
| Application Fee | Varies by project type (per COMAR) |
| Review Timeline | 90 days (standard) to 150 days (with hearing) |
| Right to Intervene | Yes, for competitors who can show adverse impact |
Market Concentration
Who benefits from the lack of competition?
Dominant System
MedStar Health
~$9.0 Billion Revenue (FY25)
Dominant System
Johns Hopkins Health
~$8.7 Billion Revenue (FY23)
Dominant System
UMMS
~$1.85 Billion Revenue (Flagship)
Insurer Market Share (Fully Insured)
61.5%
CareFirst BCBS
21.3%
Kaiser
17.2%
Others
The Human Cost
Documented cases of patient harm or access denial.
No Public Record of Denials
Our investigation found no publicly documented instances of the Maryland Health Care Commission formally denying a Certificate of Need application. While approvals are noted in reports, specific details on denied projects, withdrawn applications under pressure, or legal challenges are not made available. This lack of transparency makes it impossible to quantify the full chilling effect of the law on potential healthcare innovators and the patients they would serve.
Reform Status
Has Maryland made progress in rolling back CON?
Limited Reforms
Maryland has not undertaken a wholesale repeal of its CON program. Reforms have been piecemeal, focusing on adjusting capital thresholds for inflation (2006) and tightening the criteria for competitor interventions (2023). These changes do not fundamentally alter the restrictive nature of the law.
Entrenched System
With 100% of its acute-care hospitals owned by large systems and a commercial insurance market dominated by two carriers, the state\'s healthcare economy is a consolidated fortress. The CON law serves as the primary defense mechanism, protecting incumbents from new competition and preserving the status quo.
The Rojas Report Take
Maryland’s Certificate of Need program is not a regulatory tool; it is a state-sanctioned cartel. With a score of 95 out of 100, it stands as one of the most formidable barriers to competition in the nation. The data is unequivocal: 100% of the state’s hospitals are consolidated into systems, and a single insurer, CareFirst, controls a staggering 61.5% of the fully insured market. This is not a free market; it is a closed loop where established giants are protected from innovation and disruption.
The law’s defenders will point to minor tweaks—adjusting capital thresholds in 2006 or refining intervention rules in 2023—as evidence of progress. This is a smokescreen. Raising the cost of entry and making it slightly harder for a competitor to object does nothing to dismantle the fundamental anti-competitive structure. The complete absence of public records on CON denials is perhaps the most damning fact; the law works not by saying \'no,\' but by ensuring no one even dares to ask.
Maryland’s CON law is the legal architecture of a healthcare monopoly.
Explore Related Investigations
National Overview
The National CON Investigation
See how all 19 CON states compare.
Investigation
West Virginia
An in-depth look at another highly restrictive state.
Investigation
The 340B Drug Program
Investigating the controversial drug pricing scheme.