The purpose of Community First Choice is to provide certain home and community-based services and supports, as an alternative to institutional placements, to individuals who have been determined to require an institutional level of care. In this chapter, the following terms have the meanings indicated. Terms Defined. “Activities of daily living (ADLs)” means tasks or activities that include, but are not limited to: Bathing and completing personal hygiene routines; Dressing and changing clothes; Eating; Mobility, including: Transferring from a bed, chair, or other structure; Moving, turning, and positioning the body while in bed or in a wheelchair; and Moving about indoors or outdoors; and Toileting, including: Bladder and bowel requirements; Routines associated with the achievement or maintenance of continence; and Incontinence care. “Applicant” means an individual who is applying to receive services under this chapter. “Assistance” means that another individual: Physically performs the activity for the participant; Physically helps the participant to perform the activity; Monitors the participant’s performance of the activity in order to ensure health and safety; or Cues or encourages the participant to perform the activity. “Case management services” means services which assist an applicant or a participant in gaining access to waiver and other covered Medicaid services. “Case manager” means a person performing case management services under a waiver program and acting in the role of the supports planner. “Certified medication technician (CMT)” means an individual, regardless of title, who: Completes a course in medication administration approved by the Maryland Board of Nursing; Is certified by the Maryland Board of Nursing 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 10.39.01; and Routinely performs delegated nursing tasks delegated by a nurse in accordance with COMAR 10.27.11. “Community First Choice” means the Medicaid home and community-based services program implemented under this chapter in accordance with the application and any amendments to it submitted by the Department and approved by the Secretary of Health and Human Services, which authorizes the provision of certain home and community-based services under the Maryland Medical Assistance Program. Community Setting. “Community setting” means the area, district, locality, neighborhood, or vicinity where a group of people live which provides participants with opportunities to: Seek employment and work in competitive integrated settings; Engage in community life; Control personal resources; and Receive services. “Community setting” does not mean: Hospitals; Nursing facilities; Institutions for mental diseases; Intermediate care facilities for individuals with intellectual disabilities; or Other institutions. “Conflicts of interest” means real or seeming incompatibility between one’s private interests and one’s public or fiduciary duties. “Delegated nursing functions” means nursing services provided to a participant by an enrolled personal assistance worker under the supervision of a: Registered nurse in accordance with COMAR 10.27.11; or Nurse practitioner in accordance with COMAR 10.27.07. “Department” means the Maryland Department of Health, or its authorized agent acting on behalf of the Department. Home. “Home” means the participant’s place of residence in a community setting. “Home” does not mean: An assisted living program as defined in COMAR 10.07.14; A residential rehabilitation program licensed as a therapeutic group home under COMAR 10.21.07; An alternative living unit, group home, or individual family care home as defined in COMAR 10.22.01; Community-based residential facilities for individuals with intellectual or developmental disabilities licensed under COMAR 10.22.02; or Any other provider-owned or controlled residence. “Institution” means an establishment that furnishes, in single or multiple facilities, food, shelter, and some treatment or services to four or more individuals unrelated to the proprietor. “Instrumental activities of daily living” means tasks or activities that include, but are not limited to: Preparing meals; Performing light chores that are incidental to the personal assistance services provided to the participant; Shopping for groceries; Nutritional planning; Traveling as needed; Managing finances and handling money; Using the telephone or other appropriate means of communication; Reading; and Planning and making decisions. “Medicaid” means the Program, administered by the State of Maryland under Title XIX of the Social Security Act, which provides comprehensive medical and other health-related care for categorically eligible and medically needy participants. “Medically necessary” means that the service or benefit is: Directly related to diagnostic, preventive, curative, ameliorative, palliative, or rehabilitative treatment of an illness, injury, disability, or health condition; Consistent with current accepted standards of good medical practice; The most cost efficient service that can be provided without sacrificing effectiveness or access to care; and Not primarily for the convenience of the participant, the participant’s family, the provider, or the worker. “Nurse” means an individual who is currently licensed to practice nursing in the State under COMAR 10.27.01. “Nurse monitor” means a registered nurse who completes nursing assessments on participants and evaluates the delivery of care. “Nursing facility” means a facility which is participating in the Maryland Medical Assistance Program as a nursing facility pursuant to COMAR 10.09.10. “Participant” means an individual who: Has been determined to meet the qualifications for participation in Community First Choice as specified in Regulation .04 of this chapter; and Is enrolled with the Department to receive Medicaid services. “Personal assistance provider agency” means a public or private agency that: Employs or contracts with personal assistance workers; and Has been enrolled by the Program as a provider of personal assistance services. Personal Assistance Services. “Personal assistance services” means assistance specific to the functional needs of a participant with a chronic illness, medical condition, or disability. “Personal assistance services” includes: Assistance with activities of daily living and instrumental activities of daily living; and The performance of delegated nursing function. “Plan of service” means the written support plan that: Reflects what is important to the individual and what is important for his or her welfare; and Is developed with support from the supports planner with input from the individual and, when applicable, the individual’s representative. “Preauthorized” means approved by the Department or its designee before services can be rendered. “Program” means the Maryland Medicaid Program. “Provider” has the same meaning as defined in COMAR 10.09.36. “Provider agreement” means a contract between the Department and the provider for rendering the services under this chapter. “Quality plan” means the plan developed by the Department to address quality assurance and oversight. “Recommended plan of care” means the recommended service plan developed by a nurse after a face-to-face evaluation of an applicant or participant. “Representative” means: The person authorized by the individual to serve as a representative in connection with the provision of Community First Choice services and supports; The individual who signs the plan of service on the participant’s behalf; Any individual who makes decisions on behalf of the participant related to the participant’s plan of service; A legal guardian of the individual for the participant; or The parent or foster parent of a dependent minor child. “Supports planner” means an individual who coordinates services, including: Supporting development of a plan of service; Interacting with third parties on behalf of, or in conjunction with, the applicant or participant; and Ensuring an accurate plan of service is provided to the Department. “Telephonic timekeeping system” means a system developed by the Department for workers to time stamp the start and finish of services provided to a participant. “Worker” means an individual who is employed by or contracts with a personal assistance provider agency to provide personal assistance services. The following health professionals providing services under this chapter shall be licensed to practice in the jurisdiction in which services are rendered: Physicians; Registered nurses; Licensed practical nurses; Certified medication technicians; Certified nursing assistants; Occupational therapists; Physical therapists; Speech pathologists; Nutritionists; and Dietitians. To participate in the Program, a participant shall: Be determined by the Department to need the level of care provided in a hospital, nursing facility, an intermediate care facility for individuals with intellectual disabilities, an institution providing psychiatric services for individuals younger than 21 years old, or an institution for mental diseases for individuals 65 years old or older; Be eligible for Medicaid under an eligibility group defined in COMAR 10.09.24, except for Regulations .03C, .03-1—.03-3, and .05-2; and Reside at home. To be eligible for participation, a participant shall have an active plan of service. The plan of service shall: Be based on: The evaluation and recommended plan of care; and Consultation with the applicant or participant; Address the applicant’s or participant’s health and safety needs; Specify the items and services needed to safely support the participant in the community, including: A plan for receiving personal assistance services in case of an emergency; and Specific requests for items or services that substitute for human assistance; Specify the provider agency providing personal assistance services; and Include the signature of the: Participant or, when applicable, the individual’s representative; Supports planner; and Personal assistance provider agency listed within the plan of service. A participant’s eligibility for services shall be re-evaluated by the Department every 12 months, or more frequently if needed due to a significant change in the participant’s condition or needs. Participant eligibility shall be terminated if the participant: No longer meets the required level of care; No longer resides at home; Is without services for 30 consecutive calendar days; Voluntarily chooses, or the participant’s legal representative chooses on the participant’s behalf, to disenroll from the Program; Moves to another state; Is an inpatient for 30 consecutive days or more in an institutional setting, including but not limited to a chronic hospital or nursing facility; or Dies. To participate as a provider of a service covered under this chapter, a provider: Shall meet all of the conditions for participation as a Medicaid provider as set forth in COMAR 10.09.36, except as otherwise specified in this chapter; Shall obtain written verification of the qualifications of all individuals who render services on the provider’s behalf and provide a copy of the current license or credentials on request; Shall implement the reporting and follow-up of incidents and complaints in accordance with the Department’s established policy by: Reporting incidents and complaints within 24 hours of knowledge of the event; Submitting a written report within 7 calendar days on a form designated by the Department; and Notifying the local department of social services immediately if the provider has a reason to believe that the participant has been subjected to abuse, neglect, self-neglect, or exploitation, in accordance with COMAR 07.02.16; Shall agree to cooperate with required inspections, reviews, and audits by authorized governmental agents; Shall agree to provide services, and to subsequently bill the Department in accordance with the reimbursement methodology specified in this chapter, for only those services covered under this chapter which have been: Preauthorized in the participant’s plan of service; Provided in a manner consistent with the participant’s plan of service; and Identified in the provider agreement as within the scope of the provider’s Medicaid participation; Shall agree to maintain and have available written documentation of services, including dates and hours of services provided to participants, for a period of 6 years from the date of service, in a manner approved by the Department; Shall agree not to suspend, terminate, increase, or reduce services for an individual without authorization from the Department and only after consultation and input from the participant or, when applicable, the participant’s representative; Shall submit a transition plan to the case manager or supports planner and participant or, when applicable, the participant’s representative when suspending or terminating services; Shall verify Medicaid eligibility at the beginning of each month that services will be rendered; May not be a Medicaid provider or principal of a Medicaid provider that has overpayments that remain due to the Department; and Shall be free from conflicts of interest. To participate as a provider of a service covered under this chapter, a provider or its principals may not, within the past 24 months, have: Had a license or certificate suspended or revoked as a health care provider, health care facility, or direct care services worker; Been suspended or removed from participating as a Medicaid provider under COMAR 10.09.20; Undergone the imposition of sanctions under COMAR 10.09.36.08; Been subject to disciplinary action, including actions by the licensing board or any provider or principal of any provider agency; Been cited by a State agency for deficiencies which affect participants’ health and safety; or Experienced a termination of a Medicaid provider agreement or been barred from work or participation by a public or private agency due to: Failure to meet contractual obligations; or Fraudulent billing practices. A provider who renders health-related services to participants shall agree to: Periodically provide information about a participant in accordance with the procedures and forms designated by the Department; and Share and discuss the documented information at the request of the participant. Personal assistance service providers shall: Be licensed as a Residential Service Agency under COMAR 10.07.05 to provide Level Two or Level Three home care services; Employ a registered nurse who shall: Assess each new participant who requires personal assistance services; Participate in developing the worker instructions and in assigning appropriate personnel; Delegate nursing tasks, as appropriate, to a CNA or a CMT in accordance with COMAR 10.27.11; and Participate in instructing the workers who will provide the assistance, when indicated; Employ workers who will accept instruction on the personal assistance services required in the participant’s plan of service from the following: The participant or, when applicable, the participant’s representative; The nurse monitor; A treating physician or nurse practitioner; or An individual from the Department; Allow participants to have a significant role in the delivery of their specific care including: Directing the services and supports identified in their plan of service; and Exercising as much control as desired to select, train, schedule, determine duties, and dismiss the personal assistance worker in their home; Notify the Department in writing at least 45 days in advance of any: Voluntary closure; Change of ownership; Change of location; Sale of the business; Change in the name under which the provider is doing business; or Change in provider tax identification number; Include in the notice to the Department the method for informing participants and representatives of its intent to close, change ownership, change location, or sell its business; Include in the notice to the Department, and inform participants and representatives, of the transition plan developed by the agency to ensure continuity of services to participants; If applicable, apply for a new license whenever ownership is to be transferred from the person or organization named on the license to another person or organization in time to assure continuity of services; Submit a Medicaid provider application to the Department if the new owner chooses to participate in the Program; At least monthly, collect and maintain the participant’s signature, or that of the participant’s representative when applicable, verifying services rendered; and Conduct a criminal history records check on all direct service workers including nurses, in accordance with the procedure for a State criminal history records check established under Health-General Article, Title 19, Subtitle 19, Annotated Code of Maryland. A worker who performs delegated nursing services in accordance with COMAR 10.27.11 shall: If required to administer medications in accordance with the plan of service, be a certified medications technician; and If performing other delegated nursing functions, also be a certified nursing assistant. A personal assistance provider agency may not assign the participant’s representative to provide services to that participant. To participate in the Program as a supports planning provider under Regulation .15 of this chapter, a provider shall: Agree to be monitored by the Department; and Be: Identified by the Department through a solicitation process; or The area agency on aging that is enrolled to provide case management services under COMAR 10.09.54. To participate in the Program as a provider of consumer training under Regulation .16 of this chapter, a provider shall: Be a self-employed trainer or an agency that employs qualified trainers in accordance with §B of this regulation; Have demonstrated experience with the skill being taught; and Be willing to meet at the participant’s home to provide services. To participate in the Program as a provider of personal emergency response systems under Regulation .17 of this chapter, a provider shall: Be the store, vendor, organization, or company which sells, rents, installs, services, or operates the device or service; Provide or arrange for any installation, maintenance, training, or monitoring required for the device or system; Ensure that any response center is: Responsible for monitoring and responding to a notification of an emergency by the system; and Adequately staffed 24 hours a day, 7 days a week by properly trained staff; and Submit reports to the Department regarding activation and participant use no less than monthly or at a greater frequency as requested by the Department. To participate in the program as a provider of items or services that substitute for human assistance, the provider shall: Be approved and monitored by the Department; Provide or arrange for any installation, maintenance, training, or monitoring required for the proper operation of the device or system, if applicable; and Receive a referral from the participant, participant’s case manager, or supports planner, based on services preauthorized in the plan of service. To participate in the Program as a provider of home-delivered meals, the provider shall: Use a cooking facility or food preparation site that has a food service license issued by the local health department, in accordance with COMAR 10.15.03, or an appropriate license from the state in which the site is located; and Be approved for each licensing renewal based on inspections performed by State sanitarians in accordance with COMAR 10.15.03, or by the licensing authority in the state in which the site is located. To participate in the Program as a provider of assistive devices, equipment, or technology services, the provider shall be one of the following entities: A Program provider of disposable medical supplies and durable medical equipment under COMAR 10.09.12; or The store, vendor, organization, or company which sells or rents the equipment or system, subject to Department approval. To participate as a provider of accessibility adaptations a provider shall: Have a current license with the Maryland Home Improvement Commission; and Be approved by the Department. To participate in the Program as a provider of environmental assessments under Regulation .19 of this chapter, the provider shall: Be a licensed occupational therapist, or an agency or professional group employing a licensed occupational therapist; Receive a referral from the participant’s supports planner, based on services preauthorized in the plan of service; and Document the provider’s findings and recommendations on a form approved by the Program. To participate in the Program as a nurse monitoring provider under Regulation .20 of this chapter, a provider shall: Be designated by the Department through a process approved by the Centers for Medicare and Medicaid Services in accordance with §1915(b)(4) of the Social Security Act; Employ or contract with registered nurses who hold a current professional license to practice in Maryland; Agree to accept all referrals from the Department; and Agree to be monitored by the Department. The Program shall reimburse for the services specified in Regulations .14—.21 of this chapter, when, pursuant to the requirements of this chapter, these services have been preauthorized by the Department in the participant’s plan of service, billed in accordance with the payment procedures in Regulation .24 of this chapter, and documented as necessary to prevent institutionalization. The Program covers personal assistance services that are approved in the plan of service and rendered to a participant by a qualified provider in the participant’s home or a community setting. The Program covers the following services when provided by a personal assistance provider: Assistance with activities of daily living; Delegated nursing functions if this assistance is: Specified in the participant’s plan of service; and Rendered in accordance with the Maryland Nurse Practice Act, COMAR 10.27.11, and other requirements of the Maryland Board of Nursing; Assistance with tasks requiring judgment to protect a participant from harm or neglect; Assistance with or completion of instrumental activities of daily living, provided in conjunction with the services covered under §B(1)—(3) of this regulation; and Assistance with the participant’s self-administration of medications, or administration of medications or other remedies, when ordered by a physician. Personal assistance services may not include: Services rendered to anyone other than the participant or primarily for the benefit of anyone other than the participant; The cost of food or meals prepared in or delivered to the home or otherwise received in the community; or Housekeeping services, other than those incidental to services covered under §B of this regulation. Supports planning services shall: Address the individualized needs of the participant; Be sensitive to the educational background, culture, and general environment of the participant; Support the participant to self-direct services and exercise as much control as desired to select, train, supervise, schedule, determine duties, and dismiss the personal assistance worker; and Ensure freedom of choice among any willing provider for all services. Supports planning services include the following activities: Assisting the participant in developing a plan of service in consultation with the applicant or participant and any individual requested by the participant; Assisting the participant with referral, access, and coordination of services, both Medicaid and non-Medicaid, to address the participant’s needs including, but not limited to: Behavioral health; Educational services; Disposable medical supplies and durable medical equipment; Housing; Medical services; and Social services; Monitoring the provision of services to determine if services are received in accordance with the plan of service; Using information technology systems developed by the Department; Coordinating with the fiscal intermediary to assist in managing budgeted resources; Providing guidance and support to help individuals self-direct their services; and Administering funds for transition services. Consumer training includes instruction and skill building in such areas including, but not limited to, acquisition, maintenance, and enhancement of skills necessary for the participant to accomplish ADLs and IADLs. The topics covered by consumer training shall be: Targeted to the individualized needs of the participant receiving the training; and Sensitive of the educational background, culture, and general environment of the participant receiving the training. Consumer training does not include time spent by the provider: Planning, preparing, or setting up the training; or Following up after the training. The Program covers the following related to a device, system, or piece of equipment described under §B of this regulation: Purchase and installation; Monthly cost of a covered system or rented device or equipment, including monitoring, maintenance, and repair. A personal emergency response system is an electronic device or system which enables a participant to secure help in an emergency and may include but is not limited to: A device connected to the participant’s telephone or other device and programmed to signal, upon activation of a help button, a response center with properly trained staff on duty 24 hours a day, 7 days a week; A portable help button to allow for the participant’s mobility; and A motion detector when necessary for the participant’s safety. The program covers items or services that increase a participant’s independence or substitute for human assistance, to the extent that expenditures would otherwise be made for the human assistance. Each item or service shall: Be preauthorized in the participant’s plan of service as necessary to: Prevent the participant’s institutionalization; and Ensure the participant’s health, safety, and independence; Specifically relate to ADLs or IADLs within the approved plan of service; Comply with policies and procedure guidance defined by the Department; Meet necessary standards of manufacture, design, usage, and installation, if applicable; Be provided in accordance with applicable State and local building codes and pass required inspections, if applicable; and Not be prescribed primarily to provide comfort or convenience. Each item or service shall be confirmed by the Program as not covered for the participant by: Medicaid under the State Plan as durable medical equipment or pharmacy services under COMAR 10.09.03, 10.09.12, or 10.09.67; Medicare; or Any other third-party payer. The Program covers home-delivered meals provided during meal periods that personal assistance services are not provided. Home-delivered meals shall be: Delivered to the participant’s home; Intended for consumption at home; Nutritionally adequate for the participant’s age based on the Recommended Dietary Allowance (RDA) or Dietary Reference Intake (DRI), as established by the Food and Nutrition Board of the National Research Council and demonstrated by having the menus certified in writing by a physician, dietitian, or nutritionist; and At least one-third of the RDA, DRI, or therapeutic diet requirements ordered by the participant’s physician, dietitian, or nutritionist, including any ordered nutritional supplements. Technology that substitutes for human assistance includes: Environmental controls for the home or automobile; Personal computers, software, or accessories; Augmentative communication devices; Maintenance or repair of technology devices; Self-help aids that assist with activities of daily living or instrumental activities of daily living; and Assessments and training in the use of assistive technology. The Program covers an on-site environmental assessment and adaptations of a home or residence where the participant lives or will live as a participant. An environmental assessment or adaptation may not be provided before the effective date of the participant’s enrollment in services. The environmental assessment may be recommended by a multidisciplinary team in the plan of service for a participant when an environmental assessment is considered necessary to: Ensure the health and safety of a participant with special environmental needs; and Obtain additional professional advice from an occupational therapist about the: Physical structure of a participant’s home or residence; and Functional or mental limitations or disabilities of a participant as they relate to the environment. Included in the environmental assessment, as necessary, may be: An evaluation of the presence and likely progression of a disability or a chronic illness or condition in a participant; Environmental factors in the facility or home; The participant’s ability to perform activities of daily living; The participant’s strength, range of motion, and endurance; and The participant’s need for assistive devices and equipment. Based on an inspection of the home and interviews with the participant and any individual requested by the participant, the provider shall complete a form, to be reviewed by the supports planner, which details the provider’s findings and recommendations, especially relating to a participant’s need for services. The program covers the following services when provided by a nurse monitor: Being available to give instruction and to answer questions; Complying with the Department’s reportable events policy; and Maintaining an up-to-date client profile in an electronic database designated by the Department. The Program covers nurse monitoring services according to the following schedule: Contact with the participant for the purpose of reviewing participant status at a minimum of every 6 months with at least one in-person home or workplace visit every 12 months; and Additional nurse monitoring services at a frequency established in conjunction with the participant or, when applicable, the participant’s representative, based on the participant’s medical condition or clinical status. Home and Workplace Visits. The nurse monitoring provider shall use the home or workplace visit for the following purposes: To assess the participant’s condition; To assess the quality of personal assistance services; and To determine the need for discharge from personal assistance services or referral to other services. The nurse monitor shall assess the quality of personal assistance services by: Reviewing documentation related to the provision of personal assistance services; and Observing the performance of the worker, as appropriate. Definition. “Transition service” means a service that is: Not otherwise available under the Program; Approved in the plan of service; and Rendered to assist the participant in transitioning from an institution or a provider-owned residence to a home or community-based residence. Transition services may include all or some of the following: Security deposits; Essential furnishings and moving expenses; Set-up fees or deposits for utility services; and Other health and safety assurances. Transition services may not include recreational items including, but not limited to: Televisions; Cable television access; or Gaming systems. The Program shall reimburse for the services specified in Regulations .14—.21 of this chapter, if provided in accordance with the requirements of this chapter and if the service: Is recommended on the participant’s plan of service as necessary in order to: Prevent the applicant’s or participant’s admission to an institution; Safely transition the applicant or participant from an institution, such as a nursing facility, into the community; or Assure the health and safety of an applicant or participant in the community; Has been preauthorized by the Department in the participant’s plan of service; Is provided to an enrolled participant; Is medically necessary; and Is provided by a Medicaid provider who meets the conditions for participation under this chapter. Reimbursement for Personal Emergency Response System is limited to participants who: Live alone; or Have no regular caregiver for extended parts of the day and would otherwise require extensive routine supervision to ensure the participant’s health and safety. The Department shall establish a budget for personal assistance services and home-delivered meals that may be included in the participant’s plan of service, based on each participant’s assessed need. The Program does not cover the following services: Service primarily for the purpose of housekeeping unrelated to the participant’s activities of daily living, such as: Cleaning of the floor and furniture in areas not occupied by the participant; Laundry other than that incidental to services for the participant; and Shopping for groceries or household items unless in the company of the participant; Services provided by providers not approved for participation by the Department; Expenses incurred while escorting participants: To obtain medical diagnosis or treatment; To or from the participant’s workplace; or For participation in social or community activities; Expenses related to room and board for either the participant or the worker; Transition services more than 60 days post transition; Personal assistance services provided outside the State for more than 30 days per calendar year; Environmental adaptations to the home which: Are of general maintenance, such as carpeting, roof repair, and central air conditioning; Are not of direct medical or remedial benefit to the participant; Add to the home’s total square footage; or Modify the exterior of the home, other than the provision of ramps, lifts, sidewalks necessary to utilize a ramp or lift, and railings; or Experimental technology or equipment. Payment for supports planning and nurse monitoring services shall be limited to direct services to the participant and may not be made for: Administrative overhead; Travel; Internal quality monitoring activities; Staff supervision, training, or consultation; or Services rendered by an individual supports planner or nurse monitor in excess of 7 hours per day unless preauthorized by the Department in writing. Payment for environmental adaptations and technology that substitutes for human assistance is limited to a combined reimbursement of up to $15,000 over a 3-year period per participant. For technology items or services above $1,000, multiple quotes from providers are required. Request for Payment — Personal Assistance. To receive payment as a personal assistance provider agency under Regulation .14 of this chapter, a provider and its workers shall use the telephonic timekeeping system approved by the Department to: Document time; and Submit claims. Request for Payment — All Other Covered Services. To receive payment as a provider of services covered under Regulations .15—.21 of this chapter, a provider shall submit claims in accordance with procedures outlined in the Department’s billing manual. Billing time limitations are set forth in COMAR 10.09.36.06. Payments. Payments for services rendered to a participant shall be made directly to a qualified provider. A provider shall be paid the lesser of: The provider’s usual and 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. Effective May 1, 2017, for personal assistance services up to 12 hours per day, payment will be made in 15-minute units of service. For individuals who are determined to need more than 12 hours of personal assistance per day, a daily rate for the service will be paid. Rates. The Department shall publish a fee schedule for services covered under this chapter which shall be publicly available and updated at least annually or upon any changes made by the Department. Effective July 1, 2018, the Program’s rates for covered services under Regulations .14—.16, .18D, .19, and .20 of this chapter shall increase on July 1 of each year by 3 percent, subject to the limitations of the State budget. Recovery and reimbursement are as set forth in COMAR 10.09.36.07. Cause for suspension or removal and imposition of sanctions shall be as set forth in COMAR 10.09.36.08. Appeal procedures shall be as set forth in: COMAR 10.09.36.09; and COMAR 10.01.03. Appeal procedures for applicants and participants are those set forth in: COMAR 10.09.24.13; and COMAR 10.01.04. Interpretive regulatory requirements shall be 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: March 17, 2014 (41:5 Md. R. 343) Regulation .01 amended effective April 11, 2016 (43:7 Md. R. 449) Regulation .02B amended effective June 8, 2015 (42:11 Md. R. 724); April 11, 2016 (43:7 Md. R. 449); February 12, 2018 (45:3 Md. R. 156) Regulation .03 amended effective June 8, 2015 (42:11 Md. R. 724); April 11, 2016 (43:7 Md. R. 449) Regulation .04 amended effective June 8, 2015 (42:11 Md. R. 724) Regulation .04A, B amended effective April 11, 2016 (43:7 Md. R. 449) Regulation .05A amended effective February 12, 2018 (45:3 Md. R. 156) Regulation .05A, B amended effective April 11, 2016 (43:7 Md. R. 449) Regulation .05A, C amended effective June 8, 2015 (42:11 Md. R. 724) Regulation .06 amended effective June 8, 2015 (42:11 Md. R. 724); November 9, 2015 (42:22 Md. R. 1377); April 11, 2016 (43:7 Md. R. 449) Regulation .06A amended effective February 12, 2018 (45:3 Md. R. 156) Regulation .07 amended effective June 8, 2015 (42:11 Md. R. 724); April 11, 2016 (43:7 Md. R. 449); February 12, 2018 (45:3 Md. R. 156) Regulation .10D adopted effective February 12, 2018 (45:3 Md. R. 156) Regulation .13 amended effective April 11, 2016 (43:7 Md. R. 449) Regulation .14A amended effective January 30, 2017 (44:2 Md. R. 85) Regulation .15 amended effective January 30, 2017 (44:2 Md. R. 85) Regulation .15B amended effective February 12, 2018 (45:3 Md. R. 156) Regulation .15B, C amended effective June 8, 2015 (42:11 Md. R. 724); April 11, 2016 (43:7 Md. R. 449) Regulation .16 amended effective January 30, 2017 (44:2 Md. R. 85) Regulation .17A amended effective January 30, 2017 (44:2 Md. R. 85) Regulation .18 amended effective February 12, 2018 (45:3 Md. R. 156) Regulation .18E adopted effective January 30, 2017 (44:2 Md. R. 85) Regulation .19 amended effective February 12, 2018 (45:3 Md. R. 156) Regulation .19A amended effective January 30, 2017 (44:2 Md. R. 85) Regulation .20 amended effective April 11, 2016 (43:7 Md. R. 449); January 30, 2017 (44:2 Md. R. 85) Regulation .20B amended effective June 8, 2015 (42:11 Md. R. 724) Regulation .22B amended effective April 11, 2016 (43:7 Md. R. 449) Regulation .23 amended effective April 11, 2016 (43:7 Md. R. 449) Regulation .23B amended effective January 30, 2017 (44:2 Md. R. 85) Regulation .23C amended effective June 8, 2015 (42:11 Md. R. 724); February 12, 2018 (45:3 Md. R. 156) Regulation .23E, F adopted effective February 12, 2018 (45:3 Md. R. 156) Regulation .23D adopted effective November 9, 2015 (42:22 Md. R. 1377) Regulation .24 amended effective April 11, 2016 (43:7 Md. R. 449); January 30, 2017 (44:2 Md. R. 85); February 12, 2018 (45:3 Md. R. 156) Regulation .24A, E amended effective June 8, 2015 (42:11 Md. R. 724) Regulation .24F amended effective May 20, 2019 (46:10 Md. R. 486) Regulation .27 amended effective June 8, 2015 (42:11 Md. R. 724)