In this chapter, the following terms have the meanings indicated. Terms Defined. “Caregiver” means a willing and able individual who is trained in providing care to the participant. “Certified medication technician (CMT)” means an individual, regardless of title, who: Completes a 20-hour course in medication administration approved by the Maryland Board of Nursing; Is certified by the Board under COMAR 10.39.04; and Performs medication administration tasks delegated by a nurse in accordance with COMAR 10.27.11. “Certified nursing assistant (CNA)” means an individual, regardless of title, who: Is certified by the Maryland Board of Nursing under COMAR 10.39.05; and Routinely performs nursing tasks delegated by a nurse in accordance with COMAR 10.27.11. “Delegated nursing services” has the meaning stated in COMAR 10.27.11. Employment. “Employment” means the condition of having paid work. “Employment” includes job training or classes required to obtain government licensure or certification to engage in an occupation or profession, and work to fulfill requirements to obtain Temporary Cash Assistance or other public benefits. “Department” has the meaning stated in COMAR 10.09.36.01. “Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)” means the provision of preventive health care under 42 CFR §441.50 et seq., including medical and dental services, in order to assess growth and development and to detect and treat health problems in Medical Assistance recipients under 21 years old. “Electronic visit verification (EVV)” has the meaning stated in COMAR 10.09.36.03-2. “Emergency medical condition” means a health condition manifested by symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected by a prudent lay individual possessing an average knowledge of health and medicine to result in: Placing health in jeopardy; Serious impairment to bodily functions; Serious dysfunction of any bodily organ or part; or Development or continuance of severe pain. “Emergency service” means a service or care rendered to a recipient exhibiting an emergency medical condition as defined in §B(3) of this regulation. “EPSDT screen” means the complete package of various health screening procedures, required by the State periodicity schedule, or a partial screen, that an EPSDT participant receives. “Home” means the place of residence, occupied by the recipient, other than a residence or facility where private duty nursing services are included in the living arrangement by regulation or statute, or otherwise provided for payment. “Home health agency” means an agency licensed by the Department in accordance with COMAR 10.07.10. "Home health aide (HHA)” means an individual, regardless of title, 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” has the meaning stated in COMAR 10.09.36.01. “Medically necessary” has the meaning stated in COMAR 10.09.36.01. “Nurse” means a person who is licensed to practice as a registered nurse (RN) or licensed practical nurse (LPN) 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 who is eligible for and receiving services in accordance with the provisions of this chapter. “Plan of care” means an individualized care plan, written in collaboration with the participant or family, including the plan developed under COMAR 10.09.27 and 10.09.69, which outlines a plan of action to meet the goals or expected outcomes for the participant. “Preauthorization” means the approval required from the Department or its designee before services may be rendered. “Primary medical provider (PMP)” means the medical provider who functions as the principal medical provider to the participant including a physician, certified nurse midwife, or nurse practitioner. “Private duty nursing services” means skilled nursing services for recipients who require more individual and continuous care than is available under the home health program, and which are provided by a registered nurse or a licensed practical nurse, in a recipient's own home or another setting when normal life activities take the recipient outside his or her home. “Program” has the meaning stated in COMAR 10.09.36.01. “Progress note” means a signed and dated written notation by the home care nurse which: Summarizes facts about the care given and the participant's responses during a given period of time; Specifically addresses the established goals of treatment; Is consistent with the participant's plan of care; and Is written during the course of care. “Provider” has the meaning stated in COMAR 10.09.36.01. “Recipient” has the meaning stated in COMAR 10.09.36.01. “Residential service agency” means an agency licensed by the Department in accordance with COMAR 10.07.05. “School” means courses or classes for the acquisition of a General Education Diploma, high school diploma, associate's degree, or a first-time bachelor's degree. “Supervision” means authoritative, procedural guidance by a licensed registered nurse for the accomplishment of a function or activity, as well as the process of critical watching, directing, and evaluating another's performance. “Urgent service” means a service or care for a medical condition that is manifested by symptoms of sufficient severity that the absence of medical attention within 48 hours could reasonably be expected, by a prudent lay individual who possesses an average knowledge of health and medicine, to result in an emergency medical condition. “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. Nurses rendering or supervising the provision of private duty nursing services shall be licensed in accordance with licensing requirements specified in COMAR 10.09.36.02. An agency providing services pursuant to this chapter shall meet all applicable licensure and certification requirements of the jurisdiction in which the agency is providing services. Requirements for participation for nursing services are that a provider shall: Meet the general Medical Assistance provider requirements as specified in COMAR 10.09.36.03; Be licensed as a: Residential service agency under COMAR 10.07.05; or Home health agency under COMAR 10.07.10; Have on staff at least one registered nurse supervisor who: Provides and documents initial direction to the participant's caregivers and assigned nurse, CNA, or HHA regarding the provision of nursing services to the participant; Documents that each assigned nurse, CNA, or HHA providing home care services has the necessary skills to meet the participant's needs including knowledge of any medical equipment in use by the participant; Conducts and documents a monthly review of the progress notes to assure adequacy and quality of care; Makes supervisory visits in the participant's home or another site where the participant is receiving nursing services and regularly evaluates the assigned nurse’s performance of the nursing services in accordance with COMAR 10.27.09 and 10.27.10; Makes supervisory visits in the participant's home or another site where the participant is receiving CNA or HHA services and regularly evaluates their performance of the delegated nursing tasks in accordance with COMAR 10.27.11; Completes a note after each supervisory visit that becomes part of the participant's file; Provides and documents training to the participant's caregiver or caregivers and the individual or individuals providing backup to the caregiver or caregivers; and Develops an initial nursing care plan which is reevaluated 30 days after the initial assessment and modified as necessary to meet the participant's nursing needs; Ensure that each nurse, CNA, or HHA rendering services to a participant: Has a valid, nontemporary, nursing license or certification to provide nursing, CNA, or HHA services in the jurisdiction in which services are rendered; Has completed a skills checklist and demonstration of competency on an annual basis that was observed, documented, and verified by the signature of the RN supervisor or an RN designated by the supervisor; Demonstrates to the provider's nurse supervisor sufficient specialized training and experience to deliver the level of service required by each participant to whom the nurse, CNA, or HHA renders direct care; Demonstrates to the provider's nurse supervisor, on a continuing basis, the ability to carry out competently the services specified in a participant's care plan, subject to review by the Department or its designee; Participates in the multidisciplinary team process, if appropriate, including attending team meetings, for children receiving home and community-based services under COMAR 10.09.27, and renders services in accordance with the plan of care recommended by the team and approved by the Department or its designee, including any subsequent revisions to that plan; Is currently certified in cardiopulmonary resuscitation (CPR) at the time services are rendered; Provides care and services in accordance with generally accepted nursing practices; Knows how to contact the provider and the registered nurse supervisor; Provides care according to the provider's policies for the delivery of services to participants as described in §E of this regulation; Has not been convicted of, received a probation before judgment for, or entered a plea of nolo contendere to a felony of any crime involving moral turpitude or theft, or have any other criminal history that indicates behavior which is potentially harmful to participants; and If a CNA or HHA, has completed the training and been certified by the Maryland Board of Nursing as a CMT; Develop policies for the delivery of services to participants, including policies on the following: Skill assessments; Emergency procedures; Administration of drugs, including controlled substances; Clinical record maintenance; Job description and educational qualifications of all staff members; Clinical management; Infection control procedures; Disposal of biomedical waste; Maintenance of equipment; Supervision, including appropriate frequencies of direct supervision; Staffing and scheduling, including contingency plans for care of the participant in the absence of the caregiver, assigned nurse, CNA, or HHA; A quality assurance program; Procedures for resolution of complaints; and Coordination of care, when appropriate, including: Delineation of service responsibilities when other service providers are involved in a participant's care; Notification to participants of each service provider's responsibilities in these instances; and Development of a discharge plan when the participant, the participant's legal representative, or the provider terminates care; Conduct a reference check on each nurse, CNA, or HHA rendering care to a participant consisting of: A documented face-to-face interview between agency representatives and the nurse, CNA, or HHA; Documented efforts at verification of past employment history; and A criminal background check to include, when caring for a child, an application for a child care criminal history record check to the Criminal Justice Information System Central Repository, Department of Public Safety and Correctional Services, in accordance with Family Law Article, §5-561, Annotated Code of Maryland; Maintain a personnel folder at the agency's business office for each nurse, CNA, and HHA which shall include the following: Verification of current nursing license or certification; A copy of the current CPR certification; Documentation related to: The face-to-face interview; Verification that any nurse who serves a participant younger than 19 years old has past employment which shall include at least 1 year of clinical experience which includes pediatric direct patient care within the last 3 years; and Verification of the CNA or HHA’s past employment which shall include at least 1 year of clinical experience within the last 3 years; Written verification of a criminal background check; and Documentation of a completed skills checklist signed and dated by the registered nurse supervisor or the registered nurse supervisor designee and the assigned nurse, CNA, or HHA; Provide the participant or the participant's caregiver with the following written information: Name and phone number of the provider's contact person; and Name of each nurse, CNA, or HHA assigned by the provider to render services to the participant; Provide a mechanism for the timely investigation of written complaints such that: Disruption of service does not result from the filing of a complaint; Complete files are maintained on the source, category, and disposition of the complaint; A summary report of the complaint investigation is made available to the Department or the Department's designee; A summary report of the complaint investigation is made available for public inspection, upon request; and When a complaint investigation is not conducted, reasons are documented and forwarded with the complaint to the Department or the Department's designee; Provide back-up services when the assigned nurse, CNA, or HHA is unable to provide the services; Ensure a nurse, CNA, or HHA is not scheduled to work for more than a total of 60 hours per week or 16 consecutive hours and that the individual is off 8 or more hours before starting another shift unless otherwise authorized by the Department; Demonstrate on a continuing basis the capacity to provide services to participants in the amount and level required in the participant's care plan including the development of a contingency plan to assure coverage; Provide the participant or the participant's representative with: At least 14 days written notice of termination of services when it is the provider's decision to terminate and the medical condition remains unchanged; and A copy of a developed discharge plan if the participant, the participant's representative, or the provider elects to discontinue the provider's services to the participant; Ensure that each nurse, CNA, or HHA rendering services to a participant: Completes a progress note for each shift which becomes part of the participant's permanent record; Is providing services which follow the participant's care plan; and Is providing services ordered by the participant's primary medical provider before the start of care and renewed every 60 days as indicated by the participant’s primary medical provider’s signed and dated orders; Maintain sufficient documentation to demonstrate that the requirements of this chapter are met. The Program shall cover services rendered by a nurse, CNA, or HHA when the: Services are ordered by the participant's primary medical provider and renewed every 60 days after that; Services are directly related to the plan of care; Services are described in the nursing care plan and progress notes; Services are of a scope that is more individual and continuous than what is available under the home health program; Services are delivered in the recipient's home, or other setting when normal life activities take the recipient outside the home; Services include supervision of family caregivers in the home while family caregivers practice the skills necessary to provide care to the recipient in accordance with the established plan of care; Services are preauthorized in accordance with Regulation .06 of this chapter; Services are received by the participant as documented by the signature of the participant or the participant’s representative on the nursing provider’s official form; Services are determined medically necessary for a participant after the provider has completed an initial nursing assessment that reflects the participant’s need for an awake and alert caregiver; Participant has at least one caregiver willing and able to accept responsibility for the participant’s care when the nurse, CNA, or HHA is not available; Caregiver provides documentation of each of the following when applicable: The caregiver’s work schedule along with commuting times; The caregiver’s school attendance as defined in Regulation .02 of this chapter along with commuting times; and Emergency circumstances, as determined by the Department, including but not limited to the inability of the primary caregiver to provide care due to hospitalization or an acute debilitating illness for up to a 60-day period; and Services are provided only in the absence of the willing and able caregiver during sleeping hours and during the times documented in §A(11) of this regulation. The Program shall cover nursing services rendered by a registered nurse when: The complexity of the services or the condition of a participant requires the judgment, knowledge, and skills of a registered nurse in accordance with COMAR 10.27.09 and the services cannot be: Performed by a licensed practical nurse in accordance with COMAR 10.27.10; and Delegated to a CNA or HHA 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 registered nurse including signed and dated progress notes which are reviewed by the registered nurse supervisor; Supervisory visits are conducted and documented by the registered nurse supervisor based on acceptable standards of practice; and Services are preauthorized by the Department. The Program shall cover nursing services rendered by a licensed practical nurse when: The complexity of the services or the condition of a participant requires the judgment, knowledge, and skills of a licensed practical nurse in accordance with COMAR 10.27.10 and the services: Do not require the knowledge and skills of a registered nurse in accordance with COMAR 10.27.09; and Cannot be delegated to a CNA or HHA 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 licensed practical nurse including signed and dated progress notes which are reviewed by the registered nurse supervisor; Supervisory visits are conducted and documented by the registered nurse supervisor based on acceptable standards of practice; and Services are preauthorized by the Department. The Program shall cover delegated nursing services provided by a CNA or HHA who is also certified as a CMT when: The complexity of the service or the condition of a participant requires the judgment, knowledge, and skills of the CNA or HHA 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 CNA or HHA 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. The Program shall cover a provider's initial assessment of a participant's medical need for services when the assessment: Is 3 hours or less; Does not require preauthorization; Demonstrates: A comprehensive assessment of the recipient's health status; An assessment of the need for services; An assessment of the scope and duration of services to be provided; An assessment of the recipient's residence; and Consultation with the primary medical provider, and a multidisciplinary team if the participant is receiving services under COMAR 10.09.27, to confirm the need for services and to develop a plan of care; and Is conducted by a licensed registered nurse. If a need for services is confirmed during a participant's initial assessment, the registered nurse, in conjunction with the participant's primary medical provider, shall develop a care plan. When a participant also receives services under COMAR 10.09.27, the nurse or registered nurse supervisor shall participate as a member of the multi-disciplinary team and recommend a plan of care. The care plan shall be reviewed and updated to reflect the current service orders and shall include: Prognosis; Diagnoses; Treatment; Treatment goals; Services required, including specific nursing procedures; Frequency of visits (that is, hours of nursing care ordered for each day); Duration of treatment; Functional limitations; Permitted and prohibited activities; Diet; Medications; Mental status; A list of medical supplies related to each nursing procedure and how these are to be used in the participant's care: A list of durable medical equipment related to each nursing procedure and how the equipment is to be used in the participant's care; Safety measures to protect against injury; Emergency plan; Contingency plan for back-up coverage; Nurse's role in including the family in the provision of care; Plan to decrease services when the participant's condition improves or as the caregivers become better able to meet the participant's needs; and Other appropriate items. The Department may preauthorize on a short-term basis services for assessment purposes only, when medical information is insufficient to determine medical necessity; Services shall be decreased as the caregivers become better able to meet the participant's needs. The Program shall cover nursing services ordered by the participant's primary medical provider when the primary medical provider is an individual who is enrolled as a provider in the Program with an active status on the date of service. Under this chapter, the Program does not cover the following: Home health services that are covered under COMAR 10.09.04; Services rendered by a nurse, CNA, or HHA who is a member of the participant's immediate family or who ordinarily resides with the participant; Custodial services; Services not deemed medically necessary at the initial assessment or the most recent plan of care review; Services delivered by a nurse, CNA, or HHA who is not directly supervised by a registered nurse who documents all supervisory visits and activities; Services not preauthorized by the Department or the Department's designee, with the exception of the initial assessment; Services provided to a participant in a hospital, residential treatment center, or an intermediate care facility for individuals with intellectual disabilities or a residence or facility where nursing services are included in the living arrangement by regulation or statute, or otherwise provided for payment; Services not directly related to the plan of care; Services specified in the plan of care, when the plan of care has not been signed by the recipient or the recipient's legally authorized representative, the Department or the Department's designee, and the recipient's primary medical provider, when the services are covered under COMAR 10.09.27; Services described in the plan of care whenever a major change occurs in the recipient's medical condition or skilled nursing care needs; Services not ordered by the recipient's primary medical provider as a result of a partial or complete EPSDT screen; Services specified in Regulation .04 of this chapter which duplicate or supplant services rendered by the recipient's family caregivers or primary caregivers as well as other insurance, privilege, entitlement, or program services that the recipient receives or is eligible to receive; Services specified in Regulation .04 of this chapter to recipients eligible for any third-party liability coverage of those services; Services provided for the convenience or preference of the recipient or the primary caregiver rather than as required by the recipient's medical condition; Services which are not initially ordered before the start of care and renewed every 60 days by the participant's primary medical provider; Services provided by a nurse, CNA, or HHA who does not possess a valid, current, and nontemporary nursing license or certifications to provide services in the jurisdiction in which services are rendered; Services provided by a nurse, CNA, or HHA who does not have a current cardiopulmonary resuscitation (CPR) certification for the period during which the services are rendered; Direct payment for supervisory visits that do not meet acceptable standards of practice in accordance with COMAR 10.27.09, 10.27.10, and 10.27.11; Services rendered to a participant by a nurse, CNA, or HHA in the assigned staff's home; Services not documented; and Respite services. The Program shall only cover one-to-one nursing when a participant's condition requires that level of service and shared services are not an option. Nursing services may only be provided to EPSDT eligible individuals under 21 years old. The Program does not cover nursing services ordered by an: Individual who is not enrolled as a provider in the Program with an active status on the date of service; and Entity, facility, or another provider that is not an individual. The Department or the Department's designee shall preauthorize nursing services, according to medical necessity, frequency, and duration, as a prerequisite to payment beyond the initial assessment. Preauthorization is issued when: Program procedures are met; Program limitations are met; The requirements specified in this chapter are met; and The Department or the Department's designee determines that the services are medically necessary. The provider shall request the Department or the Department's designee to authorize the initiation or continuance of nursing services before the initiation or continuation of services unless services are rendered to a participant in need of emergency or urgent medical services. The provider shall request the Department or the Department's designee to authorize emergency or urgent medical services rendered to a recipient not later than the close of business the next business day after the emergency or urgent service is rendered. If nursing services in excess of the initial authorized amount are necessary, then: The assigned nurse or registered nurse supervisor shall contact the primary medical provider for approval of additional hours; and The provider shall request the Department or the Department's designee to authorize the increase in services before the initiation of change for nonemergency and nonurgent changes and not later than the close of business the next business day after the emergency or urgent service is rendered. An existing preauthorization shall remain in effect when a recipient is discharged from a hospital admission of less than or equal to 72 consecutive hours and there is no substantive change in the recipient's plan of care requiring a change in the number of authorized units of nursing services. Since preauthorization does not guarantee Program eligibility, the provider is responsible for checking for Program eligibility on the date of service. Preauthorization is only valid for services initiated within the period authorized by the Department or the Department's designee. Preauthorization is only valid for services rendered over a fixed period of time, such as: The periods designated for recipients who are served under COMAR 10.09.27; For the designated time initially ordered by the recipient's primary care provider, up to 30 days; and For intervals of 60 days after that or as considered necessary by the Department or the Department's designee. Authorization shall be rescinded by the Department or the Department's designee when: The recipient is terminated from care; The participant is admitted to a residential treatment center, an intermediate care facility for individuals with intellectual disabilities, or a nursing facility; The recipient is discharged from a hospital admission of less than or equal to 72 consecutive hours resulting in a change in the recipient's plan of care; The recipient is admitted to a hospital for a period of more than 72 consecutive hours; or The Department or the Department's designee determines that the care is no longer medically necessary. Payment procedures are as set forth in COMAR 10.09.36.04 and .06. Payments. Payments shall be made directly to a qualified provider. To receive payment for services under Regulation .04 of this chapter, a provider and its workers shall use the electronic visit verification method and data management system approved by the Department to document time and submit claims in accordance with COMAR 10.09.36.03-2. 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. Effective July 1, 2022, through December 31, 2023, rates for the services outlined in this regulation shall be as follows: $17.87 for 15 minutes of services provided by a registered nurse to one participant; $12.32 for 15 minutes of services provided by a registered nurse to each of two or more participants in the same residence; $11.58 for 15 minutes of services provided by a licensed practical nurse to one participant; $7.99 for 15 minutes of services provided by a licensed practical nurse to each of two or more participants in the same residence; $6.12 for 15 minutes of services provided by a CNA or HHA who is also certified as a CMT to one participant; $4.22 for 15 minutes of services provided by a CNA or HHA who is also certified as a CMT to each of two or more participants in the same residence; $5.08 for 15 minutes of services provided by a CNA or HHA to one participant; $3.50 for 15 minutes of services provided by a CNA or HHA to two or more participants in the same residence; and A flat rate of $71.41 per visit for a registered nurse supervisory visit of a nurse, CNA, or HHA. Effective January 1, 2024 through June 30, 2024, rates for the services outlined in this regulation shall be as follows: $19.2951 for 15 minutes of services provided by a registered nurse to one participant; $13.3101 for 15 minutes of services provided by a registered nurse to each of two or more participants in the same residence; $12.5061 for 15 minutes of services provided by a licensed practical nurse to one participant; $8.6266 for 15 minutes of services provided by a licensed practical nurse to each of two or more participants in the same residence; $6.6105 for 15 minutes of services provided by a CNA or HHA who is also certified as a CMT to one participant; $4.5611 for 15 minutes of services provided by a CNA or HHA who is also certified as a CMT to each of two or more participants in the same residence; $5.4874 for 15 minutes of services provided by a CNA or HHA to one participant; $3.7848 for 15 minutes of services provided by a CNA or HHA to two or more participants in the same residence; and A flat rate of $77.13 per visit for a registered nurse supervisory visit of a nurse, CNA, or HHA. Effective July 1, 2024, rates for the services outlined in this regulation shall be as follows: $19.8739 for 15 minutes of services provided by a registered nurse to one participant; $13.7094 for 15 minutes of services provided by a registered nurse to each of two or more participants in the same residence; $12.8813 for 15 minutes of services provided by a licensed practical nurse to one participant; $8.8854 for 15 minutes of services provided by a licensed practical nurse to each of two or more participants in the same residence; $6.8088 for 15 minutes of services provided by a CNA or HHA who is also certified as a CMT to one participant; $4.6979 for 15 minutes of services provided by a CNA or HHA who is also certified as a CMT to each of two or more participants in the same residence; $5.6520 for 15 minutes of services provided by a CNA or HHA to one participant; $3.8983 for 15 minutes of services provided by a CNA or HHA to two or more participants in the same residence; and A flat rate of $79.44 per visit for a registered nurse supervisory visit of a nurse, CNA, or HHA. The Program’s rates as specified in this regulation shall adjust each year, subject to the limitations of the State budget. The nursing services provider shall identify the individual who ordered the nursing services by recording the individual practitioner’s National Provider Identifier (NPI) number on the claim. Recovery and reimbursement are those set forth in COMAR 10.09.36.07. Cause for suspension or removal and imposition of sanctions is as set forth in COMAR 10.09.36.08. Appeal procedures are those set forth in COMAR 10.09.36.09. State regulations are interpreted as set forth in COMAR 10.09.36.10. Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland Effective date: Regulations .01—.11 adopted as an emergency provision effective May 5, 1993 (20:11 Md. R. 911); adopted permanently effective August 2, 1993 (20:15 Md. R. 1220) Regulations .01, .03—.07 amended as an emergency provision effective June 1, 1994 (21:13 Md. R. 1152); amended permanently effective September 26, 1994 (21:19 Md. R. 1635) Regulations .01 and .03—.06 amended as an emergency provision effective January 1, 1997 (23:26 Md. R. 1856); amended permanently effective March 10, 1997 (24:5 Md. R. 408) Regulation .01B amended effective August 23, 1999 (26:17 Md. R. 1323); January 31, 2005 (32:2 Md. R. 146); August 27, 2007 (34:17 Md. R. 1507); March 10, 2008 (35:5 Md. R. 641); April 1, 2014 (41:6 Md. R. 379); August 21, 2023 (50:16 Md. R. 726) Regulation .02 amended effective January 31, 2005 (32:2 Md. R. 146) Regulation .03 amended effective January 31, 2005 (32:2 Md. R. 146); April 1, 2014 (41:6 Md. R. 379) Regulation .03C, H amended effective August 23, 1999 (26:17 Md. R. 1323) Regulation .03D, G amended effective March 10, 2008 (35:5 Md. R. 641) Regulation .04 amended effective March 10, 2008 (35:5 Md. R. 641); April 1, 2014 (41:6 Md. R. 379) Regulation .04A amended effective June 24, 2024 (51:12 Md. R. 619) Regulation .04A, C amended effective August 23, 1999 (26:17 Md. R. 1323); January 31, 2005 (32:2 Md. R. 146) Regulation .04I adopted effective January 1, 2018 (44:26 Md. R. 1214) Regulation .05 amended effective April 1, 2014 (41:6 Md. R. 379); June 24, 2024 (51:12 Md. R. 619) Regulation .05A amended effective August 23, 1999 (26:17 Md. R. 1323); January 31, 2005 (32:2 Md. R. 146); March 10, 2008 (35:5 Md. R. 641) Regulation .05C repealed effective March 10, 2008 (35:5 Md. R. 641) Regulation .05E adopted effective January 1, 2018 (44:26 Md. R. 1214) Regulation .06 amended effective August 23, 1999 (26:17 Md. R. 1323); January 31, 2005 (32:2 Md. R. 146); April 1, 2014 (41:6 Md. R. 379) Regulation .06A amended effective August 27, 2007 (34:17 Md. R. 1507) Regulation .07 amended effective July 3, 2006 (33:13 Md. R. 1064); October 31, 2011 (38:22 Md. R. 1345); April 1, 2014 (41:6 Md. R. 379); October 24, 2016 (43:21 Md. R. 1166); May 20, 2019 (46:10 Md. R. 486) Regulation .07B amended as an emergency provision effective January 1, 2000 (27:2 Md. R. 140); amended permanently effective May 1, 2000 (27:8 Md. R. 798) Regulation .07B amended as an emergency provision effective June 12, 2008 (35:14 Md. R. 1243); amended permanently effective December 1, 2008 (35:24 Md. R. 2077) Regulation .07B amended effective April 6, 2009 (36:7 Md. R. 524); August 21, 2023 (50:16 Md. R. 726) Regulation .07C amended effective November 14, 2022 (49:23 Md. R. 995); August 21, 2023 (50:16 Md. R. 726); May 11, 2026 (53:9 Md. R. 413) Regulation .07D amended as an emergency provision effective July 1, 2007 (34:15 Md. R. 1347); amended permanently effective September 24, 2007 (34:19 Md. R. 1650) Regulation .07D amended as an emergency provision effective June 12, 2008 (35:14 Md. R. 1243); amended permanently effective December 1, 2008 (35:24 Md. R. 2077) Regulation .07D amended effective March 22, 2010 (37:6 Md. R. 477) Regulation .07E repealed effective March 10, 2008 (35:5 Md. R. 641) Regulation .07F adopted effective January 1, 2018 (44:26 Md. R. 1214)