SB 204
Department of Legislative Services
Maryland General Assembly
2021 Session
FISCAL AND POLICY NOTE
Enrolled - Revised
Senate Bill 204 (Senator Beidle)
Finance Health and Government Operations
Health Care Facilities - Assisted Living Programs - Requirements for
Alzheimer's Special Care Units and Regulations
This bill requires the Maryland Department of Health (MDH), for Alzheimer’s special care
units, to (1) establish the number of dementia-specific training hours to be completed by
staff; (2) determine the topic content for such training; and (3) require staff sufficient to
meet the needs of residents. Uncodified language requires MDH, by December 1, 2022, to
convene interested stakeholders to revise assisted living regulations (using the draft dated
September 30, 2016, as a starting point) and adopt revised regulations for assisted living
programs that incorporate the bill’s requirements for Alzheimer’s special care units. The
bill takes effect July 1, 2021.
Fiscal Summary
State Effect: MDH can convene stakeholders and adopt regulations using existing
budgeted resources, as discussed below. Revenues are not affected.
Local Effect: None.
Small Business Effect: None as a result of the bill, as discussed below.
Analysis
Current Law: An “assisted living program” is a residential or facility-based program that
provides housing and supportive services, supervision, personalized assistance,
health-related services, or a combination of such services that meets the needs of
individuals who need assistance with the activities of daily living. In Maryland, assisted
living programs are licensed by MDH’s Office of Health Care Quality (OHCQ).
Under Code of Maryland Regulations (COMAR) 10.07.14.30, an Alzheimer’s special care
unit within an assisted living program must submit a written description of the special care
unit to MDH. The assisted living program must also provide a written description of
changes made to the special care unit at the time of license renewal. The description must
include, as specified, (1) a mission statement; (2) how special care unit services are
different from other services provided by the program; (3) staff training and job titles;
(4) admission procedures; (5) assessment and service planning protocol; (6) staffing
patterns; (7) a physical environment description; (8) a description of activities for residents;
(9) a fee or fee structure; (10) discharge criteria and procedures; (11) any services, training,
or other procedures above those provided in the existing program; and (12) any other
information MDH may require. MDH must restrict admission to or close the special care
unit if the facility has not demonstrated compliance with regulations, or if the health or
safety of residents is at risk.
Regulations for assisted living programs (COMAR 10.07.14) were significantly rewritten
in 2008, with few amendments since. Proposed regulations were promulgated in 2015 and
2016; however, those regulations were not incorporated. The proposed regulations can be
found here.
The Oversight Committee on the Quality of Care in Nursing Homes and Assisted Living
Facilities evaluates the progress in improving the quality of nursing home and assisted
living facility care in the State. In its 2020 report to the Governor and General Assembly,
the oversight committee found that the quality of care in nursing homes and assisted living
facilities can improve from OHCQ’s previously planned update to assisted living
regulations.
State Fiscal Effect: MDH can convene interested stakeholders and promulgate the
regulations specified under the bill within existing budgeted resources. The Department of
Legislative Services (DLS) notes that a fiscal analysis will be conducted when the
regulations are proposed. As such, expenditures likely increase by an indeterminate, but
potentially significant, amount for Medicaid (50% general funds, 50% federal funds) and
OHCQ after regulations are adopted.
In fiscal 2018, Medicaid reimbursed $22.9 million (50% general funds, 50% federal funds)
for 324,468 units of service per diem in memory care and Alzheimer’s disease units at
assisted living programs. Depending on the specific standards adopted in the regulations,
MDH estimates an approximate increase of $15 per diem to account for new training,
continuing education, and staffing ratio requirements. For illustrative purposes only, if this
rate increase were applied to fiscal 2018 units of service, Medicaid expenditures would
increase by $4.9 million (50% general funds, 50% federal funds) annually absent any
utilization increases. MDH further advises that annual contractual costs of $600,000 are
required to enhance and maintain electronic systems and that enforcement of the new
SB 204/ Page 2
standards (as required by the bill) necessitates the hiring of two full-time health policy
analysts at an annual cost of approximately $180,000. Any impact on Medicaid as a result
of the bill is indeterminate until the regulations are adopted and implemented.
Small Business Effect: MDH advises there are 1,650 assisted living programs in the State,
the majority of which are small businesses. According to the Maryland Chapter of the
Alzheimer’s Association, approximately 80 assisted living programs currently have a
memory care unit. However, DLS advises there is no impact on small business assisted
living programs until after regulations are promulgated under the bill.
Additional Information
Prior Introductions: None.
Designated Cross File: HB 416 (Delegate Belcastro) - Health and Government
Operations.
Information Source(s): Maryland Chapter of the Alzheimer’s Association; Maryland
Department of Health; Department of Legislative Services
Fiscal Note History: First Reader - February 9, 2021
rh/jc Third Reader - March 22, 2021
Revised - Amendment(s) - March 22, 2021
Enrolled - April 7, 2021
Revised - Amendment(s) - April 7, 2021
Analysis by: Amberly Holcomb Direct Inquiries to:
(410) 946-5510
(301) 970-5510
SB 204/ Page 3


Statutes affected:
Text - First - Health Care Facilities – Assisted Living Programs – Memory Care and Alzheimer’s Disease Unit Regulations: 19-1805 Health General
Text - Third - Health Care Facilities - Assisted Living Programs - Regulations: 19-1805 Health General
Text - Enrolled - Health Care Facilities - Assisted Living Programs - Requirements for Alzheimer's Special Care Units and Regulations: 19-1805 Health General, 2-022 Health General