In this chapter, the following terms have the meanings indicated. Terms Defined. “Administrative Service Organization (ASO)” means the contractor procured by the State to provide the Department with administrative support services to operate the Maryland Public Behavioral Health System. “Behavioral Health Administration (BHA)” means the administration within the Department that establishes regulatory requirements that behavioral health programs are to maintain in order to become licensed by the Department. “Community-based substance use disorder program” means a program that provides services in community settings not regulated by the Health Services Cost Review Commission. “DATA 2000 waived provider” means a provider who has received a waiver under the Drug Addiction and Treatment Act of 2000 which expands the clinical context of medication assisted opioid dependency treatment and permits qualified physicians, nurse practitioners, and physician assistants to dispense or prescribe certain narcotic medications that have a lower risk of abuse, like buprenorphine, in settings other than an opioid treatment program. “DEA” means the Drug Enforcement Administration of the U.S. Department of Justice. “Department” means the Maryland Department of Health, as defined in COMAR 10.09.36.01, or its authorized agents acting on behalf of the Department. “Discharge plan” means a written description of specific goals and objectives to assist the participant upon leaving treatment. “Documentation” means the written medical record. “Individualized treatment plan” means a written plan of action that is developed and periodically updated and revised to address a participant’s specific service needs. “License” means the approval issued to a program by the BHA or its designee that permits a behavioral health provider to operate in Maryland. “Medical Assistance” has the meaning stated in COMAR 10.09.24.02. “Medically necessary” has the meaning stated in COMAR 10.09.36.01. “Medication management” means a visit with a physician, nurse practitioner, or physician assistant for the purpose of evaluation, prescribing, and providing medications for substance use disorder symptom reduction, withdrawal management, or medication assisted treatment. “Participant” means an individual who is certified as eligible for, and is receiving, Medical Assistance benefits. “Peer recovery support services” means a set of nonclinical activities provided by individuals in recovery from behavioral health concerns, including substance use or addictive disorders or mental health concerns, who use their personal, lived experiences and training to support other individuals with substance use or addictive disorders. “Program” has the meaning stated in COMAR 10.09.36.01. “Progress note” means an objective documentation of the participant’s progress in relation to specific treatment goals and objectives. “Recovery support services” means community-based services provided to people and their families during the initiation, on-going, and post-acute stages of their recovery from substance abuse. “Substance use disorder” means a maladaptive pattern of substance use leading to clinically significant impairment or distress and manifested by recurrent and significant adverse consequences related to the repeated use of substances. “Substance use disorder services” means the services for which a participant’s diagnosis and treatment provider meet the criteria specified in COMAR 10.67.08 and this chapter. “Telehealth” has the meaning stated in COMAR 10.09.49.02. “Treatment plan” means a written plan that addresses the individual’s biopsychosocial needs through goals and objectives and is updated as needed according to the treatment modality. To participate in the Program, a provider shall meet the license requirements stated in COMAR 10.09.36.02 and 10.63.01.03. A provider shall be in compliance with COMAR 10.09.36.03 and 10.63.01.05. A provider of community-based substance use disorder services shall include: Community-based substance use disorder providers that: Are licensed by the Department as community-based substance use disorder providers pursuant to the requirements listed in Regulation .05 of this chapter; Maintain verification of licenses and credentials of all professionals employed by or under contract with the provider in their respective personnel files; and Require any physician assistant employed by the provider to have a delegation agreement with the supervising physician in accordance with COMAR 10.09.55.02 and .03; Federally qualified health centers in compliance with COMAR 10.09.08; or Opioid treatment programs that: Are licensed by the Department’s Behavioral Health Administration; Are approved by the U.S. Drug Enforcement Administration; and Comply with 42 CFR Part 8. A provider of substance use disorder services shall maintain adequate documentation of each contact with a participant as part of the medical record, which, at a minimum, includes: The date of service with start and end times; Documents all services received by the participant; The participant’s primary reason for the substance use disorder visit; A description of the service provided; Progress notes; and An official e-Signature, or a legible signature, along with the printed or typed name of the individual providing care, with the appropriate degree or title. The providers shall make the documentation required under Regulation .05C available, as requested to carry out required activities, to: The Department; The ASO; The Core Service Agency; The Local Addictions Authority; The Local Behavioral Health Authority; The Office of Inspector General of the Department; and The Office of the Attorney General Medicaid Fraud Control Unit. A provider shall comply with all federal statutes and regulations, including the Health Insurance Portability and Accountability Act, 42 U.S.C. §1320D et seq., and implementing regulations at 45 CFR Parts 160 and 164. If delivering services via telehealth, a provider shall comply with COMAR 10.09.49 and any subregulatory guidance issued by the Department. A participant may self-refer or be referred to substance use disorder treatment by a: Provider; Family member; Caregiver; or Local health authority. An individual is eligible for substance use disorder services if: The individual meets the Department’s medical necessity criteria; and The service is appropriate to the specific provider type or community-based substance use disorder providers listed in Regulation .05 of this chapter. Comprehensive substance use disorder assessment at a minimum shall: Be delivered through: A BHA licensed substance use disorder treatment provider; or An opioid treatment program; Be completed before providing the community based behavioral health services listed in §§BI of this regulation; Be reviewed and approved by a licensed physician or licensed practitioner of the healing arts, within the scope of his or her practice under State law; and Include: An assessment of the following areas: Drug and alcohol use; and Substance use disorder treatment history; Referrals for physical and mental health services; and Recommendation for the appropriate level of substance use disorder treatment. Peer recovery support services shall: Be included as part of a written individualized treatment plan that includes specific individualized goals; Be delivered through a BHA licensed: Outpatient substance use disorder treatment provider in compliance with COMAR 10.63.03.06, 10.63.03.03 or 10.63.03.07; or Opioid treatment program in compliance with COMAR 10.63.03.19; Be provided by staff who, at a minimum: Maintains active certification by BHA or its designee; Self-identifies as an individual with life experience of being diagnosed with behavioral health concerns, including substance use disorders, addictive disorders, or mental health concerns; Completes ongoing training as approved by BHA or its designee; and Receives supervision by: A registered peer supervisor approved by BHA or its designee; or An individual practitioner as defined in COMAR 10.09.59.04A(2) or a certified alcohol and drug counselor who is approved to supervise by the relevant board and who must be an approved registered peer supervisor on or after September 1, 2023; and Be provided directly to the participant either in-person or via telehealth. Level 1 group and individual substance use disorder counseling shall: Comply with COMAR 10.63.03.06; Be delivered through: A BHA licensed substance use disorder treatment provider; or An opioid treatment program; Include services for participants who require less than 9 hours weekly for adults and 6 hours weekly for adolescents; Include a written individualized treatment plan, with the participation of the participant based on the comprehensive assessment that shall: Be reviewed and approved by a licensed physician or licensed practitioner of the healing arts, within the scope of his or her practice under State law; and Include: Participant treatment plan goals; Referrals to ancillary services, if needed; and Referral to recovery support services, if needed; and Include family members, if necessary, as long as the participant is also present in a Level 1 group counseling session. Level 2.1 Intensive Outpatient services shall: Comply with COMAR 10.63.03.03; Be delivered through a BHA licensed substance use disorder treatment provider only; Include services for participants who require outpatient treatment for 9 or more hours weekly for an adult and 6 or more hours weekly for an adolescent; Include a written individualized treatment plan, with the participation of the participant based on the comprehensive assessment that shall: Be reviewed and approved by a licensed physician or licensed practitioner of the healing arts, within the scope of his or her practice under State law; and Include: Participant treatment plan goals; and Specific interventions that reflect the amounts, frequencies and intensities appropriate to the objective of the treatment plan; and Include a discharge plan, which includes written recommendations to assist the participant with continued recovery efforts, as well as appropriate referral services. Level 2.5 partial hospitalization services shall: Comply with COMAR 10.63.03.07; Be delivered through a BHA licensed substance use disorder treatment provider; Include services for participants who require a minimum of 20 hours weekly of structured outpatient treatment delivered in the following ways: Half day sessions with a minimum of 2 hours per day of services; or Full day sessions with a minimum of 6 hours per day of services; Include a written individualized treatment plan, with the participation of the participant based on the comprehensive assessment that shall: Be reviewed and approved by a licensed physician or licensed practitioner of the healing arts, within the scope of his or her practice under State law; and Include: Participant treatment plan goals; and Specific interventions that reflect the amounts, frequencies and intensities appropriate to the objective of the treatment plan; and Include a discharge plan, which includes written recommendations to assist the participant with continued recovery efforts, as well as appropriate referral services. Ambulatory withdrawal management service shall: Comply with COMAR 10.63.03.18; Be delivered through a BHA licensed substance use disorder treatment provider; Include the following services as medically necessary: Administration and monitoring of medication, including administration and monitoring of psychotropic medication by qualified staff, as necessary; and Managing withdrawal symptoms; and Include a participant progress note added to the participant-s record after each session. Buprenorphine and other medication assisted treatment delivered by a BHA licensed substance use disorder treatment provider that employs a practitioner who holds a DEA registration with Schedule III authority in compliance with 21 U.S.C. §823 shall include the following: Services delivered by a DEA registered practitioner with Schedule III authority, including: Pharmacological interventions, including the use of FDA-approved opiate agonist and partial agonist treatment medications to provide treatment, support, and recovery to opioid-addicted participants; At a minimum, medical services required to be provided by the Program that: Ensure that participants receive a dose adequate to alleviate withdrawal symptoms; Employ dose increases and behavior therapy before mandatory detoxification for participants continuing to use drugs; Establish participant dosing based on an individual need; Provide flexible dosage tapering and withdrawal management with dosage reductions at the participant’s request; Ordering and administering non-narcotic drugs; and Services provided by alcohol and drug counselors and other staff as appropriate, including: Substance use disorder and related counseling as recommended in the individualized treatment plan; and Point of care presumptive drug testing that shall be: Presumptive in nature and performed at the point of care; and Capable of being read by direct optical observation only. For dates of service before January 1, 2023, BHA licensed substance use disorder treatment providers rendering buprenorphine and other medication assisted treatment are required to comply with requirements for DATA 2000 waived providers. Opioid maintenance therapy services delivered through the use of methadone or buprenorphine by opioid treatment programs shall comply with 10.63.03.19 and include: An individualized treatment plan that shall be reviewed and approved by a licensed physician or licensed practitioner of the healing arts, within the scope of his or her practice under State law; The following services: Pharmacological interventions, including the use of FDA-approved opiate agonist and partial agonist treatment medications to provide treatment, support, and recovery to opioid-addicted participants; Point of care presumptive drug testing; Definitive drug testing when completed by a laboratory; Substance use disorder and related counseling as recommended in the individualized treatment plan; Periodic medication management; Medical services, including, but not limited to, those required to be provided by the Program that ensure that participants receive a dose adequate to alleviate withdrawal symptoms; and Ordering and administering non-narcotic drugs; A discharge plan, which includes written recommendations to assist the participant with continued recovery efforts, as well as appropriate referral services; and Guest dosing arrangements with other opioid treatment programs, as medically necessary. Medication assisted treatment induction service delivered by opioid treatment programs shall include the following services, as medically necessary: Pharmacological interventions, including the use of one of the following FDA-approved opiate agonist and partial agonist treatment medications to provide treatment, support, and recovery to opioid-addicted participants: Buprenorphine; or Methadone; Medical services, including, but not limited to, those required to be provided by the Program that ensure that participants receive a dose adequate to alleviate withdrawal symptoms; and Ordering and administering non-narcotic drugs. The Program under this chapter does not cover the following: Community-based substance use disorder services not specified in Regulation .05 of this chapter; Community-based substance use disorder services not approved by a licensed physician or other licensed practitioner of the healing arts, within the scope of his or her practice under State law; Services not identified by the Department as medically necessary or listed in Regulation .05 of this chapter; Investigational and experimental drugs and procedures; Substance use disorder visits solely for the purpose of: Prescribing medication; Administering medication; Drug or supply pick-up; Collecting laboratory specimens; Interpreting laboratory tests or panels; or Administering injections, unless the following are documented in the participant’s medical record: Medical necessity; and The participant’s inability to take appropriate oral medications; Services that are provided in a hospital inpatient or outpatient setting or in an intermediate care facility for behavioral health; Services beyond the provider’s scope of practice; Services that are separately billed but included as part of another service; Buprenorphine induction and buprenorphine maintenance therapy services that are: Delivered by a participant’s primary care provider which are the responsibility of the Managed Care Organization as specified in COMAR 10.67.08; or Delivered without a primary diagnosis of substance use disorder; Presumptive and definitive drug testing when billed by: An opioid treatment program; An intensive outpatient program; or A partial hospitalization program provider; ( Peer recovery support services that are not provided either in-person or via telehealth; and Services not authorized consistent with this chapter. Providers may not be reimbursed by the Program for: More than one comprehensive substance use disorder assessment for a participant per provider per 12-month period unless there is a break in treatment over 30 calendar days; More than one Level 1 group counseling session per day per participant; More than six Level 1 individual counseling units as measured in 15 minute increments per day per participant; More than four sessions of Level 2.1 Intensive Outpatient treatment per week; Level 1 group or individual counseling during the same week as a Level 2.1 Intensive Outpatient treatment or Level 2.5 Partial Hospitalization service unless the participant has been discharged from or admitted to a new level of care; Overlapping episodes of Level 2.1 Intensive Outpatient treatment and Level 2.5 Partial Hospitalization; Level 1 group or individual counseling during the same week as Level 1 group or individual counseling offered by another provider; Psychiatric day treatment service as described in COMAR [10.09.02.01] 10.63.03.08 or an intensive outpatient mental health service on the same day as a Level 2.1 Intensive Outpatient program or Level 2.5 Partial Hospitalization program Buprenorphine maintenance therapy delivered by an opioid treatment program or a BHA licensed substance use disorder treatment provider during the same week as Methadone Maintenance Therapy; Ambulatory withdrawal management during the same week as an opioid maintenance therapy, medication assisted treatment induction, or buprenorphine maintenance service; Medication management billed by an opioid treatment program or a BHA licensed substance use disorder treatment provider during the same days as medication assisted treatment induction; Community-based substance use disorder services on the same day that a participant received similar services as a hospital inpatient or outpatient; Services delivered by federally qualified health centers other than those billed using T-codes that may include the following delivered by two separate appropriately licensed providers: One T-code for mental health services per day with associated mental health procedure code; and One T-code for substance use disorder services with associated H-code per day; Services rendered but not appropriately documented to the level of service; Services rendered by mail; Completion of forms or reports; Broken or missed appointments; Travel to and from site of service; and Transportation costs. In order to bill for an individual in Level 2.1 Intensive Outpatient treatment, the per diem session shall include a minimum of 2 hours. A maximum of 4 per diems may be billed per week. In order to bill for an individual in Level 2.5 Partial Hospitalization, the per diem rate for a half day session shall include a minimum of 2 hours. In order to bill for an individual in Level 2.5 Partial Hospitalization, the per diem rate for a full day session shall include a minimum of 6 hours. The Department shall pay participating opioid treatment programs, per participant, per week provided the participant received ongoing opioid treatment medications and at least one face-to-face documented treatment service in the month for which the Program is billed. In order for an opioid treatment program to bill for medication assisted treatment induction, the provider shall bill this service only in the first week of treatment per participant or in the first week of treatment after a break from treatment of at least 6 months. In order for an opioid treatment program to bill for buprenorphine maintenance therapy, the provider shall bill this service per participant per week. In order to bill for ambulatory withdrawal management, providers may bill up to 5 per diems during the detoxification episode if determined medically necessary by the Department. Peer recovery support services may not be used to supplant the minimum billing requirements for: Level 2.1 Intensive Outpatient treatment as described in §C of this regulation; Level 2.5 Partial Hospitalization half day session as described in §D of this regulation; Level 2.5 Partial Hospitalization full day session as described in §E of this regulation; and Opioid treatment program services as described in §F of this regulation. All drug screening lab claims submitted to the ASO by providers other than opioid treatment programs shall list the applicable substance use disorder diagnosis. For services outlined in Regulation .05 of this chapter, the community-based substance use disorder program shall notify the ASO and obtain authorization to provide substance use disorder services from the ASO. The ASO agent shall authorize services that are: Medically necessary; and Of a type, frequency, and duration that are consistent with expected results and cost-effectiveness. No payment shall be rendered for services that have not been authorized by the Department or its designee. General policies governing payment procedures that are applicable to all providers are set forth in COMAR 10.09.36.04. Billing time limitations for claims submitted under this chapter are set forth in COMAR 10.09.36.06. Unless the care is free to other patients, a provider shall bill the Program their usual and customary charge to the general public. For dates of service July 1, 2023 through December 31, 2023, rates for the services outlined in this chapter shall be as follows: For services outlined in this regulation, as delivered through a BHA licensed substance use disorder treatment provider: Comprehensive substance use disorder assessment — $198.35; Level 1 group substance use disorder counseling — $54.49 per session; Level 1 individual substance use disorder counseling — $27.93 per 15-minute increment with a maximum of six 15-minute increments per day; Level 2.1 Intensive Outpatient treatment — $174.60 per diem; Level 2.5 Partial Hospitalization half day session — $181.58 per diem; Level 2.5 Partial Hospitalization full day session — $293.31 per diem; Ambulatory Withdrawal Management —$97.78 per diem; Individual peer support services — $16.87 per 15-minute increment; Group peer support services — $4.69 per 15-minute increment; Point of care presumptive drug test read with direct optical observation only — $10.02 per test; Point of care presumptive drug test read with instrument-assisted direct optical observation — $10.02 per test; Point of care presumptive drug test read with instrumented chemistry analyzers — $49.40 per test; and Periodic medication management through office-based evaluation and management visits, according to COMAR 10.09.02.07D. For services outlined in this regulation as delivered through an opioid treatment program: Comprehensive substance use disorder assessment — $198.35; Level 1 group substance use disorder counseling — $54.49 per session; Level 1 individual substance use disorder counseling — $27.93 per 15-minute increment with a maximum of six 15-minute increments per day; Opioid Maintenance Therapy — $86.27 per participant per week; Medication Assisted Treatment Induction — $279.36 per participant per week; Buprenorphine Maintenance Therapy — $76.69 per participant per week; Individual peer support services — $16.87 per 15-minute increment; Group peer support services — $4.69 per 15-minute increment; and Periodic medication management through office-based evaluation and management visits, according to COMAR 10.09.02.07D. For dates of service January 1, 2024, through June 30, 2024, rates for the services outlined in this chapter shall be as follows: For services outlined in this chapter, as delivered through a BHA licensed substance use disorder treatment provider: Comprehensive substance use disorder assessment — $214.22; Level 1 group substance use disorder counseling — $58.85 per session; Level 1 individual substance use disorder counseling — $30.16 per 15-minute increment with a maximum of six 15-minute increments per day; Level 2.1 Intensive Outpatient treatment — $188.57 per diem; Level 2.5 Partial Hospitalization half day session — $196.11 per diem; Level 2.5 Partial Hospitalization full day session — $316.77 per diem; Ambulatory Withdrawal Management —$105.60 per diem; Individual peer support services — $18.22 per 15-minute increment; Group peer support services — $5.07 per 15-minute increment; Point of care presumptive drug test read with direct optical observation only — $10.02 per test; Point of care presumptive drug test read with instrument-assisted direct optical observation — $10.02 per test; Point of care presumptive drug test read with instrumented chemistry analyzers — $49.40 per test; and Periodic medication management through office-based evaluation and management visits, according to COMAR 10.09.02.07D. For services outlined in this chapter as delivered through an opioid treatment program: Comprehensive substance use disorder assessment — $214.22; Level 1 group substance use disorder counseling — $58.85 per session; Level 1 individual substance use disorder counseling — $30.16 per 15-minute increment with a maximum of six 15-minute increments per day; Opioid Maintenance Therapy — $93.17 per participant per week; Medication Assisted Treatment Induction — $301.71 per participant per week; Buprenorphine Maintenance Therapy — $82.83 per participant per week; Individual peer support services — $18.22 per 15-minute increment; Group peer support services — $5.07 per 15-minute increment; and Periodic medication management through office-based evaluation and management visits, according to COMAR 10.09.02.07D. Effective July 1, 2024, rates for the services outlined in this chapter shall be as follows: For services outlined in this chapter, as delivered through a BHA licensed substance use disorder treatment provider: Comprehensive substance use disorder assessment — $220.65; Level 1 group substance use disorder counseling — $60.62 per session; Level 1 individual substance use disorder counseling — $31.06 per 15-minute increment with a maximum of six 15-minute increments per day; Level 2.1 Intensive Outpatient treatment — $194.23 per diem; Level 2.5 Partial Hospitalization half day session — $201.99 per diem; Level 2.5 Partial Hospitalization full day session — $326.27 per diem; Ambulatory Withdrawal Management —$108.77 per diem; Individual peer support services — $18.77 per 15-minute increment; Group peer support services — $5.22 per 15-minute increment; Point of care presumptive drug test read with direct optical observation only — $10.02 per test; Point of care presumptive drug test read with instrument-assisted direct optical observation — $10.02 per test; Point of care presumptive drug test read with instrumented chemistry analyzers — $49.40 per test; and Periodic medication management through office-based evaluation and management visits, according to COMAR 10.09.02.07D. For services outlined in this chapter as delivered through an opioid treatment program: Comprehensive substance use disorder assessment — $220.65; Level 1 group substance use disorder counseling — $60.62 per session; Level 1 individual substance use disorder counseling — $31.06 per 15-minute increment with a maximum of six 15-minute increments per day; Opioid Maintenance Therapy — $95.97 per participant per week; Medication Assisted Treatment Induction — $310.76 per participant per week; Buprenorphine Maintenance Therapy — $85.31 per participant per week; Individual peer support services — $18.77 per 15-minute increment; Group peer support services — $5.22 per 15-minute increment; and Periodic medication management through office-based evaluation and management visits, according to COMAR 10.09.02.07D. The Program shall make no direct payment to participants. The Department shall authorize supplemental payment on Medicare claims only if: The provider accepts Medicare assignments; Medicare makes direct payment to the provider; Medicare has determined that the services are medically necessary; The services are covered by the Program; and Initial billing is made directly to Medicare according to Medicare guidelines. The Department shall make payment on Medicare claims subject to the following provisions: Deductible and coinsurance shall be paid in full for services designated as mental health services by Medicare; and The Program shall reimburse services not covered by Medicare, but considered medically necessary by the Program, according to the limitations of this chapter. Recovery and reimbursement shall be as set forth in COMAR 10.09.36.07. Causes for suspension or removal and imposition of sanctions shall be as set forth in COMAR 10.09.36.08. The Department shall give to the provider reasonable written notice of the Department’s intention to impose sanctions. In the notice, the Department shall: Establish the: Effective date of the proposed action; and Reasons for the proposed action; and Advise the provider of the right to appeal. Appeals procedures shall be as set forth in accordance with COMAR 10.09.36.09. This chapter shall be interpreted as set forth in COMAR 10.09.36.10. Health-General Article, §§2-104(b), 7.5-204, 7.5-205(d), 7.5-402, 8-204(c)(1),15-103(a)(1), and 15-105(b), Annotated Code of Maryland Effective date: Regulations .01—.09 adopted as an emergency provision effective January 1, 2010 (37:6 Md. R. 474); adopted permanently effective May 31, 2010 (37:11 Md. R. 765) Chapter revised effective December 22, 2014 (41:25 Md. R. 1480) Regulation .01B amended effective October 26, 2015 (42:21 Md. R. 1302); April 10, 2017 (44:7 Md. R. 356); November 14, 2022 (49:23 Md. R. 996); May 15, 2023 (50:9 Md. R. 379); August 5, 2024 (51:15 Md. R. 708) Regulation .02 amended effective October 26, 2015 (42:21 Md. R. 1302); September 25, 2017 (44:19 Md. R. 897) Regulation .03 amended effective October 26, 2015 (42:21 Md. R. 1302); November 14, 2022 (49:23 Md. R. 996) Regulation .03A, B amended effective September 25, 2017 (44:19 Md. R. 897) Regulation .04 amended effective October 26, 2015 (42:21 Md. R. 1302) Regulation .05 amended effective October 26, 2015 (42:21 Md. R. 1302); April 10, 2017 (44:7 Md. R. 356); September 25, 2017 (44:19 Md. R. 897); November 14, 2022 (49:23 Md. R. 996); May 15, 2023 (50:9 Md. R. 379); August 5, 2024 (51:15 Md. R. 708) Regulation .06 amended effective October 26, 2015 (42:21 Md. R. 1302); April 10, 2017 (44:7 Md. R. 356); May 15, 2023 (50:9 Md. R. 379) Regulation .06A, B amended effective November 14, 2022 (49:23 Md. R. 996) Regulation .07C amended effective October 26, 2015 (42:21 Md. R. 1302) Regulation .08 amended effective October 26, 2015 (42:21 Md. R. 1302); November 14, 2022 (49:23 Md. R. 996); May 15, 2023 (50:9 Md. R. 379); November 24, 2025 (52:23 Md. R. 1139) Regulation .08D amended effective October 24, 2016 (43:21 Md. R. 1166); April 10, 2017 (44:7 Md. R. 356); January 1, 2018 (44:26 Md. R. 1215); December 30, 2019 (46:26 Md. R. 1164) Regulation .08D – F amended August 5, 2024 (51:15 Md. R. 708)