# COMAR Title 10 — Maryland Department of Health

## Subtitle 09 — Medical Care Programs

### Chapter 01 — Advanced Practice Nurse Services

**Authority:** Health-General Article, §§2-104(b), 15-103, 15-105, and 15-141.2, Annotated Code of Maryland

**Administrative History of COMAR 10.09.01 Eligibility:** Note: For the current Medical Assistance Eligibility regulations, see COMAR 10.09.24 and 10.09.25.

**Administrative History of COMAR 10.09.01 Eligibility:** Effective date: May 1, 1975 (2:7 Md. R. 525)

**Administrative History of COMAR 10.09.01 Eligibility:** Amended effective January 7, 1976 (3:1 Md. R. 41) and March 17, 1976 (3:6 Md. R. 358); amended as an emergency provision effective November 23, 1976 (3:26 Md. R. 1535)

**Administrative History of COMAR 10.09.01 Eligibility:** Chapter revised effective April 27, 1977 (4:9 Md. R. 714)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .01CCC adopted effective November 23, 1977 (4:24 Md. R. 1805)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .02A amended as an emergency provision effective July 1, 1977 (4:13 Md. R. 1026); adopted permanently effective September 23, 1977 (4:20 Md. R. 1545)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .02A amended effective April 4, 1980 (7:7 Md. R. 707)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .02B amended effective November 23, 1977 (4:24 Md. R. 1805)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulations .04B, C and .05B amended effective October 3, 1980 (7:20 Md. R. 1878)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .05C amended as an emergency provision effective July 1, 1977 (4:12 Md. R. 945); adopted permanently effective September 23, 1977 (4:20 Md. R. 1545); amended as an emergency provision effective November 10, 1977 (4:25 Md. R. 1910); adopted permanently effective March 10, 1978 (5:5 Md. R. 325)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .05C repealed effective October 3, 1980 (7:20 Md. R. 1878)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .06B amended as an emergency provision effective January 1, 1978 (5:1 Md. R. 14); adopted permanently effective May 5, 1978 (5:9 Md. R. 683)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .06B amended effective July 1, 1978 (5:13 Md. R. 1051)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .06B amended as an emergency provision effective July 2, 1979 (6:14 Md. R. 1202); adopted permanently effective November 2, 1979 (6:22 Md. R. 1779)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .06B amended effective July 1, 1980 (7:13 Md. R. 1278)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .06B amended as an emergency provision effective July 1, 1982 (9:13 Md. R. 1346); adopted permanently effective November 1, 1982 (9:19 Md. R. 1894)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .08A amended effective December 26, 1980 (7:26 Md. R. 2422)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulations .09 and .10B amended as an emergency provision effective August 15, 1977 (4:16 Md. R. 1205); adopted permanently effective November 23, 1977 (4:24 Md. R. 1805)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulations .10B and .11B amended effective December 28, 1979 (6:26 Md. R. 2073)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .10D repealed effective August 8, 1980 (7:16 Md. R. 1594)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .10D adopted as an emergency provision effective November 1, 1982 (8:21 Md. R. 1703); adopted permanently effective March 1, 1982 (9:4 Md. R. 331)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .11D amended as an emergency provision effective July 1, 1977 (4:12 Md. R. 945); adopted permanently effective September 23, 1977 (4:20 Md. R. 1545); amended as an emergency provision effective August 15, 1977 (4:16 Md. R. 1205); adopted permanently effective November 23, 1977 (4:24 Md. R. 1805); amended effective December 1, 1978 (5:24 Md. R. 1797); amended effective December 28, 1979 (6:26 Md. R. 2073)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .12A amended as an emergency provision effective January 1, 1983 (10:3 Md. R. 207); emergency status extended at 10:8 Md. R. 720; emergency status expired April 30, 1983

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .16C amended effective October 3, 1980 (7:20 Md. R. 1878)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .17 adopted effective February 14, 1983 (10:3 Md. R. 209)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .18A amended effective January 31, 1983 (10:2 Md. R. 109)

**Administrative History of COMAR 10.09.01 Eligibility:** Regulation .18B adopted as an emergency provision effective July 26, 1982 (9:17 Md. R. 1696); emergency status extended at 9:23 Md. R. 2254; adopted permanently effective November 30, 1982 (9:23 Md. R. 2259)

**Administrative History of COMAR 10.09.01 Eligibility:** Chapter repealed effective May 1, 1983 (10:6 Md. R. 558)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Effective date: May 14, 1990 (17:9 Md. R. 1090)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Regulation .01 amended effective May 31, 1999 (26:11 Md. R. 854)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Regulation .02C amended effective May 31, 1999 (26:11 Md. R. 854)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Regulations .02 and .03 amended as an emergency provision effective September 16, 1992 (19:20 Md. R. 1812); amended permanently effective January 1, 1993 (19:25 Md. R. 2205)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Regulation .05G, Q amended effective May 31, 1999 (26:11 Md. R. 854)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Regulation .06 amended as an emergency provision effective January 28, 1991 (18:3 Md. R. 301); emergency status expired April 8, 1991 (18:9 Md. R. 1004)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Regulation .06 amended as an emergency provision effective April 9, 1991 (18:9 Md. R. 1005); amended permanently effective October 7, 1991 (18:18 Md. R. 2004)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Regulation .06C,D,G amended effective July 4, 2016 (43:13 Md. R. 712)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Regulation .06E amended effective May 31, 1999 (26:11 Md. R. 854)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Regulation .06F amended effective April 4, 2011 (38:7 Md. R. 430)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Regulation .06K adopted effective May 31, 1999 (26:11 Md. R. 854)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Regulations .01—.10 under Nurse Practitioner Services repealed and new Regulations .01—.08 under Advanced Practice Nurse Services adopted effective August 28, 2017 (44:17 Md. R. 834)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Regulation .03 amended effective August 21, 2023 (50:16 Md. R. 725)

**Administrative History of COMAR 10.09.01 Advanced Practice Nurse Services:** Regulation .06H, I amended effective August 21, 2023 (50:16 Md. R. 725)

#### Regulation .01 Definitions.

*COMAR 10.09.01.01*

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

  (1) “Advanced practice nurse” means a:

    (a) Certified nurse practitioner;

    (b) Certified nurse midwife; or

    (c) Certified registered nurse anesthetist.

  (2) “Board” means the Maryland State Board of Nursing.

  (3) “Certified nurse midwife (CNM)” means a registered nurse who is:

    (a) Certified by the Board to practice nurse midwifery under COMAR 10.27.05;

    (b) Certified by the American College of Nurse-Midwives; or

    (c) Certified by the American Midwifery Certification Board.

  (4) “Certified nurse practitioner” means:

    (a) A registered nurse who, by reason of certification under COMAR 10.27.07, may practice in Maryland as a nurse practitioner under the terms of that chapter; or

    (b) If out-of-State, a registered nurse who qualifies as a nurse practitioner in the state in which services are provided.

  (5) “Certified registered nurse anesthetist (CRNA)” means a registered nurse who is certified to practice nurse anesthesia by the Board under COMAR 10.27.06.

  (6) “Department” means the Maryland Department of Health, as defined in COMAR 10.09.36.01.

  (7) “Medicare” means the insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq.

  (8) “Participant” means an individual who is certified as eligible for and is receiving Medical Assistance benefits.

  (9) “Physician” means an individual who meets the licensure requirements and conditions of participation of COMAR 10.09.02.

  (10) “Program” means the Maryland Medical Assistance Program.

  (11) “Provider” means an advanced practice nurse who, through appropriate agreement with the Department, has been identified as a Program provider by the issuance of a provider number.

#### Regulation .02 License and Certification Requirements.

*COMAR 10.09.01.02*

A. The provider shall:

  (1) Meet all license requirements as set forth in COMAR 10.09.36.02; and

  (2) Be licensed and hold all certifications as required by the Board.

B. If practicing out-of-State, the provider shall meet the regulatory requirements of the state in which the services are provided.

#### Regulation .03 Conditions for Participation.

*COMAR 10.09.01.03*

To participate in the Program, a provider shall:

A. Meet all conditions for participation as set forth in COMAR 10.09.36.03; and

B. If delivering services via telehealth, comply with COMAR 10.09.49 and any subregulatory guidance issued by the Department.

#### Regulation .04 Covered Services.

*COMAR 10.09.01.04*

A. Subject to §B of this regulation, the Program covers medically necessary services rendered to participants as follows:

  (1) For nurse practitioners:

    (a) Medically necessary services within the provider’s scope of practice as described in COMAR 10.27.07; or

    (b) If out-of-State, nurse practitioner services authorized in the state in which the services are provided;

  (2) For nurse midwives:

    (a) Medically necessary services within the provider’s scope of practice as described in COMAR 10.27.05; or

    (b) If out-of-State, nurse midwife services authorized in the state in which the services are provided;

  (3) For certified registered nurse anesthetists:

    (a) Medically necessary services within the provider’s scope of practice and in collaboration with an authorized provider as described in COMAR 10.27.06; or

    (b) If out-of-State, certified registered nurse anesthetist services authorized in the state in which the services are provided;

  (4) Laboratory services when the advanced practice nurse is not required to register their office as a medical laboratory pursuant to Health-General Article, Title 17, Subtitle 2, Annotated Code of Maryland; and

  (5) Drugs and supplies within the advanced practice nurse’s scope of practice.

B. The services in §A of this regulation shall be:

  (1) Medically necessary; and

  (2) Described in the participant’s medical record in sufficient detail to support the invoice submitted for those services.

#### Regulation .05 Limitations.

*COMAR 10.09.01.05*

Under this chapter, the Program does not cover the following:

A. Services not medically necessary;

B. Services prohibited by the Maryland Nurse Practice Act or by the Board;

C. Advanced practice nursing services included as part of the cost of:

  (1) An inpatient facility;

  (2) A hospital outpatient department; or

  (3) A freestanding clinic;

D. Visits by or to the provider solely for the purpose of the following:

  (1) Prescription, drug, or food supplement pick-up;

  (2) Recording of an electrocardiogram;

  (3) Ascertaining the patient’s weight;

  (4) Interpretation of laboratory tests or panels; or

  (5) Prescribing or administering medication;

E. Drugs and supplies which are acquired by the provider at no cost;

F. Injections and visits solely for the administration of injections, unless medical necessity and the patient's inability to take oral medications are documented in the patient's medical record;

G. Services paid under the free-standing dialysis program as described in COMAR 10.09.22;

H. Immunizations required for travel outside the continental United States;

I. Prescriptions and injections for central nervous system stimulants and anorectic agents when used for weight control;

J. Acupuncture;

K. Hypnosis;

L. Travel expenses;

M. Investigational or experimental drugs and procedures;

N. Services denied by Medicare as not medically justified;

O. Specimen collection, except by venipuncture and capillary or arterial puncture, as a separate service;

P. Laboratory or X-ray services performed by another facility, which shall be billed to the Program directly by the facility; and

Q. For certified nurse midwives, a separate visit charge on date of delivery.

#### Regulation .06 Payment Procedures.

*COMAR 10.09.01.06*

A. The provider shall submit the request for payment in the format designated by the Department.

B. The Department reserves the right to return to the provider, before payment, all requests for payment not properly completed.

C. The provider shall charge the Program the provider's:

  (1) Customary charge to the general public for similar services; and

  (2) Acquisition cost for injectable drugs or dispensed medical supplies.

D. The provider shall be paid the lesser of:

  (1) The provider's customary charge to the general public unless the service is free to individuals not covered by the Program; or

  (2) The Program rates as described in COMAR 10.09.02.07.

E. If a service is free to individuals not covered by the Program:

  (1) The provider:

    (a) May charge the Program; and

    (b) Shall be reimbursed in accordance with §D of this regulation; and

  (2) The provider's reimbursement is not limited to the provider's customary charge.

F. Payments on Medicare claims are authorized, if:

  (1) Services are covered by the Program;

  (2) The provider accepts Medicare assignments;

  (3) Medicare makes direct payment to the provider;

  (4) Medicare has determined that services were medically justified; and

  (5) Initial billing is made directly to Medicare according to Medicare guidelines.

G. The Department shall make supplemental payments on Medicare claims subject to the following provisions:

  (1) Deductible insurance shall be paid in full; and

  (2) Coinsurance shall be paid at the lesser of:

    (a) 100 percent of the coinsurance amount; or

    (b) The balance remaining after the Medicare payment is subtracted from the Program rate.

H. The provider may not bill the Program for:

  (1) Completion of forms and reports;

  (2) Broken or missed appointments; or

  (3) Professional services rendered by mail.

I. The Program may not make direct payment to participants.

J. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.

K. The Program shall reimburse for all medical laboratory services according to the fees established under COMAR 10.09.09.

L. An advanced practice nurse who is employed by or under contract to any physician, clinic, or hospital may not bill for any service for which reimbursement is sought by the physician, clinic, or hospital.

M. The Program may not reimburse nurse midwives for prenatal or postpartum care once the patient has been referred to a physician for completion of prenatal or postpartum care.

#### Regulation .07 Recovery and Reimbursement.

*COMAR 10.09.01.07*

Recovery and reimbursement are as set forth in COMAR 10.09.36.07.

#### Regulation .08 Causes for Suspension or Removal and Imposition of Sanctions.

*COMAR 10.09.01.08*

Causes for suspension or removal and imposition of sanctions are as set forth in COMAR 10.09.36.08.