In this chapter, the following terms have the meanings indicated. Terms Defined. “Certified nursing assistant” means an individual who: Is certified by the Maryland Board of Nursing; and Performs nursing tasks delegated by a registered nurse or licensed practical nurse pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland. “Department” means the Maryland Department of Health as defined in COMAR 10.09.36. “Disabled child” means a chronically ill or severely impaired child, younger than 22 years old, whose illness or disability may not require 24-hour inpatient care, but which, in the absence of home care services, may precipitate admission to or prolong stay in a hospital, nursing facility, or other long term care facility. “Face-to-face” means contact with a participant that occurs in-person or via audio-visual telehealth in accordance with COMAR 10.09.49. “Home care” means a comprehensive package of medical and health-related services provided under the Program, pursuant to the authority of a model waiver for certain disabled children, as an alternative to institutionalization. “Home care case management” means locating, coordinating, and monitoring home care services for disabled children and includes: Screening of referrals and identification of individuals requiring home care services; Completing a comprehensive assessment to determine the appropriateness of home care services; Convening the multidisciplinary team and coordinating the development of a comprehensive plan of care; Determining individual case cost effectiveness; Identifying and maximizing informal sources of care; Ongoing monitoring of the delivery of services specified in the plan of care to determine the appropriateness of the type, amount, and duration of services rendered; Completing the semiannual utilization review procedure specified in Regulation .03B(1)(c)(ii) of this chapter; and Providing in-home assessments as specified in Regulation .04A(2)(e) of this chapter. “Home care case manager” means the agency administering a program of services for disabled children authorized under Title V of the Social Security Act, or the agency's designee, which provides or arranges for the provision of home care case management services for participants, develops training and community education programs, and establishes standards and procedures for quality assurance and monitoring. “Home care provider” means the principal physician or the individual or agency providing nursing, home health aide services, medical supplies and equipment, or home care case management services to disabled children. “Home health agency” means an agency licensed by the Department in accordance with COMAR 10.07.10. “Home health aide” means an individual who meets all the conditions of participation specified in: 42 CFR §484.36; and Health Occupations Article, Title 8, Annotated Code of Maryland. “Medical Assistance Program” means the Medical Assistance Program as defined in COMAR 10.09.36. “Medical day care” has the meaning stated in COMAR 10.09.07. “Medical day care center” has the meaning stated in COMAR 10.09.07. “Medicare” means Medicare as defined in COMAR 10.09.36. “Model Waiver” means the document and any amendments to it submitted by the Department to, and approved by, the Department of Health and Human Services which authorize the waiver of certain statutory requirements limiting eligibility and covered services under the Medicaid State plan pursuant to §1915(c) of the Social Security Act. “Multidisciplinary team” means the group consisting of the participant or the participant's legal representative or representatives, or all of these, home care providers, and the participant's principal physician or the physician designated by the principal physician, and other providers of health-related services, as appropriate, that establishes and updates the plan of care under the overall direction and coordination of the home care case manager and assesses the appropriateness of the participant's discharge to or continuation of home care. “Necessary” means necessary as defined in COMAR 10.09.36. “Nurse” means a person who is licensed as a registered nurse or licensed practical nurse in the jurisdiction in which services are provided. “Nursing care plan” means a plan developed by a registered nurse that identifies: The patient's diagnoses and needs; The goals to be achieved; and The interventions required to meet the patient's medical condition. “Participant” means a recipient: Whose initial eligibility for services under this chapter is established as a disabled child certified by the Department or its designee as requiring nursing home care under the Program pursuant to COMAR 10.09.10 or COMAR 10.09.11, or inpatient hospital care pursuant to COMAR 10.09.92—10.09.95, but whose medical condition does not require 24-hour inpatient care unless home care services are not available; Who, once eligibility is established, remains eligible for services under this chapter as long as he or she continues to meet the certification and care requirements of §B(15)(a) of this regulation, regardless of age; Who, but for the services listed in Regulation .04 of this chapter, requires and would be receiving institutional care reimbursed under the Program; Who, before receipt of services under this chapter, was: A patient in a hospital, nursing facility, or other long-term care facility; or Formerly a patient in a hospital, nursing facility, or other long-term facility who, upon discharge, has continuously received other insurance reimbursement for skilled nursing or home health aide services which has precluded the need for admission to the waiver; Whose disabilities and needs for home care cannot be adequately and appropriately addressed through provider services otherwise available under the Program; and Who meets the eligibility requirements of these regulations or was receiving services under this chapter as of December 1, 1988 or under COMAR 10.09.31 as of December 31, 1990 and continues to meet the certification and care requirements specified in this chapter. “Plan of care” means the written home care plan which is: Composed of a comprehensive assessment of the participant's health status including: All pertinent diagnoses; Prognosis; Functional status; Level of activity permitted; Type, frequency, and duration of services required; Treatment goals for each type of service; Medications; and Treatments; Established by the multidisciplinary team; Approved, signed, and dated by the participant's principal physician; Approved, signed, and dated by the participant or the participant's legally authorized representative, or both; Approved, signed, and date by the Department; and Revised 90 days after approval of the initial plan of care and semiannually thereafter, unless the home care case manager decides that a different review period is appropriate. “Principal physician” means the specialty physician who is part of the interdisciplinary team and who approves the plan of care for the participant. “Program” means the Program as defined in COMAR 10.09.36. “Progress note” means a dated written notation by a home care provider which: Summarizes facts about the care given and the patient's responses during a given period of time; Specifically addresses the established goals of treatment; Is consistent with the participant's plan of care; Is written and signed during the course of care; and Is provided to the home care case management agency to become a part of the agency's permanent record for the participant. “Provider” means a provider as defined in COMAR 10.09.36. “Provider agreement” means a contract between the Department and the provider of home care, specifying the services to be performed, methods of operation, and financial and legal requirements which shall be in force before Program participation. “Recipient” means a recipient as defined in COMAR 10.09.36. “Residential service agency” means an agency licensed by the Department in accordance with COMAR 10.07.05. “Secretary” means the Secretary of Health. “Specialty physician” means a licensed physician who meets one of the following criteria: Has been declared board certified, or board eligible, by a member board of the American Board of Medical Specialties, and has demonstrated experience in the care of disabled children; or Has been declared board certified, or board eligible, by a specialty board approved by the Advisory Board of Osteopathic Specialists and the Board of Trustees of the American Osteopathic Association, and has demonstrated experience in the care of disabled children. “Supervision” means: Authoritative procedural guidance by a licensed registered nurse for the accomplishment of a function or activity; and The process of critical watching, directing, and evaluating an individual's performance. “Telehealth” has the meaning stated in COMAR 10.09.49.02. “Waiver enrollment process” means those procedures necessary to establish participant eligibility pursuant to Regulation .05 of this chapter. “Witness” means the recipient or an individual who, on behalf of the recipient, is able to personally verify that the recipient received private duty nursing services, home health aide services, or certified nursing assistant services. Providers shall meet all licensing requirements specified in COMAR 10.09.36. General requirements for participation in the Medical Assistance Program are that providers shall meet all conditions for participation specified in COMAR 10.09.36. Specific requirements for participation in the Program as a provider of home care services are as follows: The home care case management provider shall: Have a written agreement with each participant which includes the following: A description of the types, amount, frequency, and duration of home care services to be provided to the participant as ordered by the principal physician and specified in the approved plan of care; A statement that the participant or responsible representatives shall have access to the individual plan of care and shall be involved in its development and periodic review; The name, address, telephone number, and Medical Assistance number of the participant; The dated signatures of the participant or legally authorized representative, and the provider representative; A statement that utilization of available services and selection among approved enrolled providers is subject to participant choice; A statement that services will at all times be provided without discrimination with regard to race, color, age, sex, national origin, marital status, or physical or mental handicap. Be available to participants in-person at least 8 hours a day, 5 days a week with established hours of operation. Have written and implemented formalized policies and procedures developed before participation in the Program concerning the following areas: Medical records for each participant which include at a minimum the application for home care, plan of care, orders for home care services, documentation of nursing observations at least every 30 days, social history, and home care cost worksheets establishing initial participant eligibility and continued eligibility on a quarterly basis; Utilization review which includes the development of a home care review procedure completed every 6 months for all participants to evaluate the appropriateness of home care, the efficiency, adequacy, and coordination of home care services, with the objective of achieving the least costly yet appropriate delivery of services under the Program. Convene the multidisciplinary team which: Upon receipt of the principal physician's orders assesses the appropriateness of home care for the participant; Determines the medical, psychological, social, and functional status of each participant; Develops an individual plan of care in conjunction with the principal physician's orders; Coordinates at least one in-person meeting annually, unless otherwise authorized by the Department; Unless otherwise excepted in §B(1)(d)(iv) of this regulation, may meet in-person or via telehealth; and Reviews and updates the individual plan of care in accordance with Regulation .01B(16) of this chapter. Provide for in-home assessments, via an in-person visit or telehealth, on a quarterly basis or as determined necessary by the principal physician. Conducts at least two in-person visits annually, unless otherwise authorized by the Department. Not be a provider of medical supplies and equipment or nursing services. Shift private duty nursing, certified nursing assistant, and home health aide providers shall: Meet all conditions for participation set forth in: COMAR 10.09.53.03; or COMAR 10.09.69; Participate in interdisciplinary team meetings; Ensure timesheets are signed by the individual rendering services; Ensure a nurse, a certified nursing assistant, or a home health aide is not scheduled to work for more than 16 consecutive hours and the individual is off 8 or more hours before starting another shift unless otherwise authorized by the Department; Provide for in-home assessments by the principal physician, on a quarterly basis or as determined necessary by the principal physician. Either be a: Residential service agency licensed in accordance with COMAR 10.07.05; or Home health agency licensed in accordance with COMAR 10.07.10 which meets the conditions of participation specified in 42 CFR §484.36; Demonstrate the capacity to arrange for the provision of home health aide services in the amount and level required in the participant's plan of care including the establishment of a contingency plan to assure coverage as specified in the plan of care; Demonstrate sufficient specialized training and experience in the care of individuals with disabilities necessary to deliver the level of services required by participants; and Demonstrate, on a continuing basis, the ability to competently carry out services in the plan of care subject to review by the home care case manager or the home care case manager's designee. Medical day care providers shall meet all conditions for participation set forth in COMAR 10.09.07. The provider of home care services shall: Deliver services in-person unless expressly authorized to render services via telehealth; and If delivering services via telehealth, comply with COMAR 10.09.49 and any subregulatory guidance issued by the Department. The Program reimburses for home care services which include the following: Shift nursing services provided by a licensed registered nurse or a licensed practical nurse if: The complexity of the service or the condition of a participant requires the judgment, knowledge, and skills of a licensed nurse for a shift of 4 or more continuous hours; The services are delivered to the participant in the participant's home or other setting when normal life activities take the participant outside the home; Services are provided to a model waiver participant who is 21 years old or older; Services are rendered in accordance with COMAR 10.09.53; Services are rendered in accordance with Health Occupations Article, Title 8, Annotated Code of Maryland; Sufficient documentation concerning the services provided is maintained by the registered nurse or licensed practical nurse, including: Verification of the participant's receipt of services as documented by the participant's signature or the signature of the participant's witness on the provider's official forms; and Signed and dated progress notes which are reviewed monthly by the nurse supervisor; The nurse is not scheduled to work for more than 16 consecutive hours and is off 8 or more hours before starting another shift; Services are rendered by a licensed registered or practical nurse certified in cardiopulmonary resuscitation and the certification is renewed every 2 years; Services are preauthorized in accordance with the criteria set forth in COMAR 10.09.53.06; and Supervisory visits are conducted at least monthly in the participant's home or another site where the participant is receiving nursing services with a minimum of two visits per year with the primary nurse present; Home care case management which includes: Arranging, monitoring, and coordinating the health-related services necessary to meet the identified needs of the participant as specified in the participant's plan of care; Establishing, in conjunction with the other members of the multidisciplinary team, the plan of care necessary to deinstitutionalize or maintain, or both of these, the participant at home; Reviewing the plan of care for appropriateness of the level, amount, type, quality, and frequency of services provided as well as monitoring the cost effectiveness of home care for each participant; Arranging for scheduled reviews and approval of the plan of care by the principal physician; and Providing for in-home assessments, via an in-person visit or telehealth as authorized by the Department, on a quarterly basis, or as determined necessary by the principal physician; Participation by the principal physician in the plan of care meetings including: Prescribing home care services; and Approving and signing the plan of care; Home health aide services which include: The performance of simple procedures as an extension of therapy services; Ambulation and exercise; Household services essential to health care at home; Assistance with medications that are ordinarily self-administered; Assistance with activities of daily living when performed in conjunction with other delegated nursing services; Other health care services properly delegated by a licensed nurse pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland, if: The complexity of the service or the condition of a participant requires the judgment, knowledge, and skills of a home health aide for a shift of 4 or more continuous hours; Services are provided by an unlicensed individual who meets all the conditions of participation specified by the Medicare program in 42 CFR §484.36 and Health Occupations Article, Title 8, Annotated Code of Maryland; Services are rendered by a home health aide certified in cardiopulmonary resuscitation and the certification is renewed every 2 years; The home health aide is not scheduled to work for more than 16 consecutive hours and has 8 hours or more off before starting another shift; Sufficient documentation is maintained by the home health aide including verification of the participant's receipt of services as documented by the participant's signature or the signature of the participant's witness on the provider's official forms; and signed and dated progress notes which are reviewed every 2 weeks by the nurse supervisor; Supervisory visits are conducted every 2 weeks and documented by a registered nurse with a minimum of two visits with the primary aide present; The services are included in the model waiver participant's plan of care developed by the case manager; and Services are preauthorized by the Department; Certified nursing assistant services if: The certified nursing assistant is certified by the Maryland Board of Nursing and meets all the requirements to render services pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland; The complexity of the service or the condition of a participant requires the judgment, knowledge, and skills of a certified nursing assistant for a shift of 4 or more continuous hours; The services provided include but are not limited to: Assistance with activities of daily living when performed in conjunction with other delegated nursing services; or Other health care services properly delegated by a licensed nurse pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland; Services are rendered by a certified nursing assistant certified in cardiopulmonary resuscitation and the certification is renewed every 2 years; The certified nursing assistant is not scheduled to work for more than 16 consecutive hours and has 8 hours or more off before starting another shift; Sufficient documentation concerning the services provided is maintained by the certified nursing assistant including: Verification of the participant's receipt of services as documented by the participant's signature or the signature of the participant's witness on the provider's official forms; and Signed and dated progress notes which are reviewed every 2 weeks by the nurse supervisor; Supervisory visits are conducted every 2 weeks and documented by a registered nurse with a minimum of two visits with the primary aide present; The services are included in the model waiver participant's plan of care developed by the case manager; and Services are preauthorized by the Department; Delegated nursing services provided by a certified nursing assistant or home health aide who is also a certified medical technician when: The complexity of the service or the condition of a participant requires the judgment, knowledge, and skills of the certified nursing assistant or home health aide for at least 2 or more continuous hours; The services provided include but are not limited to: Assistance with activities of daily living when performed in conjunction with other delegated nursing services; or Other nursing services properly delegated by a nurse pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland, and in accordance with COMAR 10.27.11; Sufficient documentation is maintained by the certified nursing assistant or home health aide, including signed and dated progress notes which are reviewed by the nurse supervisor; and Supervisory visits are conducted and documented by a registered nurse supervisor in accordance with COMAR 10.27.09 and 10.27.11; and Medical day care when services are: Included in the Model Waiver participant's approved and signed plan of care; and Rendered in accordance with COMAR 10.09.07. The Department will reimburse for the services listed in §A(1)—(2) and (4)—(6) of this regulation when they are: Ordered by the participant's principal physician as part of a written home care plan, which is included in the provider's permanent record for the participant and is reviewed by the principal physician in accordance with Regulation .01B(16) of this chapter; Medically necessary; Adequately described in progress notes in the participant's medical record, signed, and dated by the individual providing care; Provided instead of institutional care to recipients certified and annually recertified as requiring nursing facility care under the Program as specified in COMAR 10.09.10 or 10.09.11; and Provided in the amount, duration, and frequency specified in the plan of care subject to approval by the Program. Requirements. Model waiver participants shall meets the financial eligibility requirements under §B, C, or D of this regulation and the nonfinancial requirements of §§E and F of this regulation. Categorically needy eligibility recipients of supplemental security income benefits under Title XVI of the Social Security Act are eligible for medical assistance benefits as categorically needy individuals as specified in COMAR 10.09.24. Optional Categorically Needy Eligibility. Individuals who do not qualify for supplemental security income benefits may apply for eligibility under the provision of this section and applicable sections of COMAR 10.09.24, as follows: COMAR 10.09.24, exclusive of Regulations .06, .08L, .09, and .10, applies for the purpose of determining eligibility as an optional categorically needy individual. An individual is eligible for medical assistance benefits as an optional categorically needy individual if they comply with the requirements of §C(1) of this regulation, including the requirement that resources not exceed the applicable standard for supplemental security income eligibility, and if the income of the individual before the disregards specified in §C(3) of this regulation does not exceed 300 percent of the supplemental security income benefit amount payable under §1611(b)(i) of the Social Security Act to an individual in their own home who has no income or resources. Disregards. The following disregards are subtracted from income computed according to COMAR 10.09.24.07A—K in order to determine the amount of the income of recipients qualifying under this section to be applied toward the cost of services specified in Regulation .04 of this chapter. The amount of the medically needy income standard for one person established under COMAR 10.09.24.07; Amounts for incurred expenses for medical or remedial care that are not subject to payment by a third party, including: Medicare and other health insurance premiums, deductibles, or co-insurance charges, and Necessary medical or remedial care recognized under State law but not covered under the Program. Medically Needy Eligibility. Financial eligibility for individuals who do not qualify as categorically needy recipients as specified in §B, or optional categorically needy recipients as specified in §C of this regulation is determined according to provisions of COMAR 10.09.24 relating to determinations of medically needy eligibility. To be eligible to receive services under the model waiver for disabled children a person shall: Be certified and annually recertified as requiring nursing home care under the Program pursuant to COMAR 10.09.10 or COMAR 10.09.11; Be approved by the Department or its designee as appropriate for home care based on a comprehensive assessment of the participant's health status as set forth in Regulation .01B(15) of this chapter; Choose between institutional or home care services under the Program; Be a recipient: For whom it can reasonably be expected that the cost of home care services would not exceed the cost of the level of care provided in an institution, and Whose plan of care meets the requirement of §F of this regulation relating to cost effective coverage of home care services. Eligibility for coverage of home care services for disabled children is limited to individuals for whom the projected total cost that would be incurred by the Program if the coverage and services specified in this chapter were not available is greater, on an annual basis, than the projected total cost that would be incurred by the Program for the services listed in Regulation .04 of this chapter and all other services available under the Program based on the following formula: Payment procedures as set forth in COMAR 10.09.36 apply. Payments. Payments shall be made directly to a qualified provider. Providers shall be paid the lesser of: The provider's customary charge to the general public unless the service is free to individuals not covered by Medicaid; or The rate established according to the fee schedule published by the Department. Rates. The Department shall publish a fee schedule for services covered under this chapter that shall be publicly available and updated at least annually or upon any changes made by the Department. Effective July 1, 2022, rates for services governed by this chapter are as follows: For home health aide or certified nursing assistant services provided to one participant: $5.0809 per 15 minutes of services; or If the services are rendered by a home health aide or certified nursing assistant who is also a certified medical technician, $6.1208 per 15 minutes of services; For home health aide or certified nursing assistant services provided to two or more participants in the same residence: $3.5044 per 15 minutes of services per participant; or If the services are rendered by a home health aide or certified nursing assistant who is also a certified medical technician, $4.2232 per 15 minutes of service per participant; and Payments for home care case management services shall be made as follows: Waiver enrollment process — $1,181.61; First month of home care case management — $1,181.61; and The second and any subsequent month of home care case management — $590.80. Effective January 1, 2024 through June 30, 2024, rates for services governed by this chapter are as follows: For home health aide or certified nursing assistant services provided to one participant: $5.4874 per 15 minutes of services; or $6.6105 per 15 minutes of service if the services are rendered by a home health aide or certified nursing assistant who is also a certified medical technician; For home health aide or certified nursing assistant services provided to two or more participants in the same residence: $3.7848 per 15 minutes of services per participant; or $4.5611 per 15 minutes of service per participant if the services are rendered by a home health aide or certified nursing assistant who is also a certified medical technician; and Payments for home care case management services shall be made as follows: Waiver enrollment process — $1,276.14; First month of home care case management — $1,276.14; and The second and any subsequent month of home care case management — $638.06. Effective July 1, 2024, rates for services governed by this chapter are as follows: For home health aide or certified nursing assistant services provided to one participant: $5.6520 per 15 minutes of services; or If the services are rendered by a home health aide or certified nursing assistant who is also a certified medical technician, $6.8088 per 15 minutes of services; For home health aide or certified nursing assistant services provided to two or more participants in the same residence: $3.8983 per 15 minutes of services per participant; or If the services are rendered by a home health aide or certified nursing assistant who is also a certified medical technician, $4.6979 per 15 minutes of service per participant; and Payments for home care case management services shall be made as follows: Waiver enrollment process — $1,314.42; First month of home care case management — $1,314.42; and The second and any subsequent month of home care case management — $657.21. Subject to the limitations of the State budget, the Program’s rates as specified in this regulation shall increase by 4 percent each year through Fiscal Year 2026. Recovery and reimbursement shall be as specified in COMAR 10.09.36. Cause for suspension or removal and imposition of sanctions shall be as specified in COMAR 10.09.36. Appeal procedures shall be as specified in COMAR 10.09.36. State regulations shall be interpreted as specified in COMAR 10.09.36. Health-General Article, §§2-104(b), 15-103, 15-105, and 15-141.2, Annotated Code of Maryland Effective date: Regulations .01—.10 adopted as an emergency provision effective May 10, 1985 (12:11 Md. R. 1041); emergency status extended at 12:19 Md. R. 1843 and 13:6 Md. R. 669; adopted permanently effective March 10, 1986 (13:5 Md. R. 543) Regulations .01—.10 amended as an emergency provision effective March 11, 1991 (18:7 Md. R. 765); amended permanently effective July 1, 1991 (18:12 Md. R. 1339) Regulation .01B amended effective July 1, 1989 (16:12 Md. R. 1336) Regulation .03B amended effective August 25, 1986 (13:17 Md. R. 1922); July 1, 1989 (16:12 Md. R. 1336) Regulation .04A amended effective August 25, 1986 (13:17 Md. R. 1922); July 1, 1989 (16:12 Md. R. 1336) Regulation .04B amended effective July 1, 1989 (16:12 Md. R. 1336) Regulation .06A—C amended effective July 1, 1989 (16:12 Md. R. 1336) Regulation .06B 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) Regulation .06B 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) Regulation .06C amended effective August 25, 1986 (13:17 Md. R. 1922) Regulation .07A amended effective August 25, 1986 (13:17 Md. R. 1922) Chapter revised effective July 1, 1991 (18:12 Md. R. 1339) Regulation .01B amended effective July 17, 2006 (33:14 Md. R. 1163) Regulation .01B amended as an emergency provision effective July 1, 2008 (35:17 Md. R. 1481); amended permanently effective December 1, 2008 (35:24 Md. R. 2077); September 25, 2017 (44:19 Md. R. 896) Regulation .01B amended effective August 21, 2023 (50:16 Md. R. 725) Regulation .03B amended effective July 17, 2006 (33:14 Md. R. 1163) Regulation .03B amended as an emergency provision effective July 1, 2008 (35:17 Md. R. 1481); amended permanently effective December 1, 2008 (35:24 Md. R. 2077) Regulation .03B amended effective August 21, 2023 (50:16 Md. R. 725) Regulation .04A amended effective July 17, 2006 (33:14 Md. R. 1163); August 21, 2023 (50:16 Md. R. 725) Regulation .04A, B amended as an emergency provision effective July 1, 2008 (35:17 Md. R. 1481); amended permanently effective December 1, 2008 (35:24 Md. R. 2077) Regulation .05C amended effective August 21, 2023 (50:16 Md. R. 725) Regulation .06 amended effective May 20, 2019 (46:10 Md. R. 486) Regulation .06A, C amended effective July 17, 2006 (33:14 Md. R. 1163) Regulation .06A, C amended as an emergency provision effective July 1, 2008 (35:17 Md. R. 1481); amended permanently effective December 1, 2008 (35:24 Md. R. 2077) Regulation .06A, C amended effective July 4, 2016 (43:13 Md. R. 712) Regulation .06C amended as an emergency provision effective July 1, 2007 (34:15 Md. R. 1346); amended permanently effective October 8, 2007 (34:20 Md. R. 1739) Regulation .06C amended effective April 6, 2009 (36:7 Md. R. 523); February 8, 2010 (37:3 Md. R. 175); August 21, 2023 (50:16 Md. R. 725); November 24, 2025 (52:23 Md. R. 1139)