As Maryland looks to stand up court-ordered treatment for individuals with serious mental illness, counties, and the State are navigating implementation questions, legal gray areas, and funding shortfalls.

What is AOT?

Assisted Outpatient Treatment (AOT) is a court-ordered process for compelling outpatient mental health treatment for individuals with serious and persistent mental illness who are unable to voluntarily comply with their treatment plans. These individuals often cycle through hospitalizations, incarceration, or homelessness due to untreated symptoms, posing significant challenges to families, providers, and public safety systems.

AOT is not intended to punish or institutionalize but rather to connect individuals with care in the community and prevent serious adverse health outcomes. In fact, and as previously covered in testimony by MACo, AOT programs have been shown to reduce rates of hospitalization, arrest, and incarceration in states where it has been implemented. Petitions to the court can typically be filed by a family member or health care provider, and court oversight ensures the process protects individual rights while prioritizing treatment continuity.

Maryland’s AOT Law

Maryland was one of the last states to authorize an AOT program. Passed in 2024, Maryland’s AOT law authorized the creation of AOT programs to be administered either locally by counties or by default through the Maryland Department of Health (MDH). As initially drafted, the legislation mandated counties to establish an AOT program, which raised concerns for both fiscal and operational reasons. Read MACo’s testimony on SB 453. However, the bill underwent a series of changes, and the revisions changed MACo’s position from support with amendments to support.

The legislation required that counties inform the State of their decision to establish an AOT program by January 1, 2025, with programs to be operational by July 1, 2026. After many state and individual meetings, every jurisdiction chose to defer implementation to the State, citing unsettled questions, delayed regulations, insufficient funding, and implementation concerns. Without regulations, sustainable and sufficient funding, and solutions to implementation processes, local health departments (LHDs) and local behavioral health authorities (LBHAs) who would implement the programs locally, have concerns taking on a new program, especially given federal, state, and local budget concerns. Subsequently, LHDs were asked to reconsider after the State made clear a 100% statewide model was not feasible.

Where Are We Now?

The Maryland Behavioral Health Administration (BHA) has convened a Centralized AOT Workgroup, consisting of BHA leadership, local Health Officers, LBHAs, legislators, and other stakeholders to identify workable paths forward by the 2026 deadline. State and local partners have agreed upon a state led, regional AOT implementation structure for Maryland. However, fundamental questions remain unanswered, including issues of funding, staffing, legal representation, and program structure.

Although the law is technically in effect, no AOT programs are yet operational in Maryland. Jurisdictions continue to meet with BHA, the Workgroup, and other state officials to discuss:

• Funding and Staffing: The State has proposed $3 million for implementation, with $1 million going to the State’s own BHA. There are concerns that the remaining funding is insufficient, especially for jurisdictions that would need to pool resources regionally. LHDs and LBHAs did their own financial modeling, estimating around $500k per jurisdiction, regardless of size of jurisdiction or anticipated case load. These cost estimates do not include legal representation costs. Reimbursement models are unclear; for example, psychiatrists’ travel time may not be billable, even though staffing AOT teams in rural or multi-county regions could require extensive travel.

• Psychiatric Staffing Requirements: Under current statute and the Department of Budget Management (DBM) regulations, only psychiatrists are permitted to conduct the evaluations necessary for AOT eligibility. Currently, DBM does not allow LHDs to hire Psychiatrists in that classification so LHDs have to recruit in a lower paying classification, a situation made more challenging by the shortage of Psychiatrists and difficulty in recruiting in all areas of the state, not just in rural areas. Jurisdictions believe there would be a benefit in expanding the eligibility to include qualified nurse practitioners.

• Legal Representation: The statute does not clearly define who represents the petitioner, such as the LHD in court. While the Office of the Public Defender (OPD) will represent respondents, it remains unclear who will represent LHDs, as they are classified as state employees.

• Structural Challenges: AOT teams may be regional, but courts operate within specific jurisdictions. This misalignment raises logistical questions around court scheduling, testimony, and representation across county lines. Can hearings be scheduled efficiently? Can psychiatrists testify virtually? How would representation differ if the program is regional but the legal venue is local?

How Do Other States Implement AOT?

Maryland is one of the last states to establish an AOT framework, joining as the 49th state to authorize such a program. The implementation of AOT varies widely across the country.

New York

New York has been referred to as the model for Maryland’s AOT law. The AOT program is governed by Kendra’s Law, which mandates that every county and New York City establish a local AOT program. Counties have the option to jointly operate programs. Local mental health authorities, specifically county directors of community services, are responsible for directing and supervising these programs, either directly or through designees. According to New York’s Division of Budget, for FY2026, New York allocated $16.5 million for county AOT operations, plus $2 million to strengthen New York State Office of Mental Health oversight, demonstrating the State’s ongoing commitment to AOT as a key component of its mental health response.

California

According to the California Department of Health Care Services, California’s AOT framework is governed by Laura’s Law, which provides for court-ordered community-based treatment for individuals with serious mental illness. Under the law, passed in 2020, all counties were required to implement AOT programs by July 1, 2021, unless they formally opted out through a resolution from their Board of Supervisors explaining their rationale. California does not mandate universal local participation, but it does require counties to make an active decision. As of now, the majority of California counties have opted in, while a smaller group, mostly rural jurisdictions, have opted out.

Next Steps

AOT implementation involves a wide range of active discussions and planning efforts among stakeholders to ensure success. The next steps include estimating caseloads, finalizing regulations, clarifying legal responsibilities, securing funding, and determining necessary infrastructure. Also to be determined is how the state should be divided into AOT regions and which entities should lead them.

A multi-county regional model could help jurisdictions pool resources but would require coordination across legal, financial, and operational lines. Some statutory changes may be necessary to clarify roles and authorities. As planning continues, a phased in implementation approach, starting with a single jurisdiction or region, could offer valuable insights such as actual funding costs and help guide broader rollout decisions.

Conclusion

Maryland’s AOT law holds promise for improving care for some of the most vulnerable residents. But without clear answers to critical implementation questions and adequate resources, counties remain cautious. As conversations continue between jurisdictions, BHA, and other partners, MACo is committed to helping jurisdictions navigate this complex rollout and ensure that any implementation is both sustainable and successful.

This article is part of MACo’s Deep Dive series, where expert analysts explore and explain the top county issues of the day. A new article is added each week – read all of MACo’s Deep Dives.