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    Maryland Register
    Issue Date:  May 26, 2017
    Volume 44• Issue 11 • Pages 527—529
    Title 10
    Notice of Proposed Action
    The Secretary of Health and Mental Hygiene proposes to:
    (1) Repeal in their entirety existing Regulations .01—.10 under existing COMAR 10.09.01 Nurse Practitioner Services, and adopt new Regulations .01—.08 under a new chapter, COMAR 10.09.01 Advanced Practice Nurses Services;
    (2) Repeal in their entirety Regulations .01—.11 under COMAR 10.09.21 Nurse Midwife Services; and
    (3) Repeal in their entirety Regulations .01—.10 under COMAR 10.09.39 Nurse Anesthetists Services.
    At this time, the Secretary is also withdrawing the proposal to repeal in their entirety existing Regulations .01—10 under existing COMAR 10.09.01 Nurse Practitioner Services and adopt new Regulations .01—.08 under a new chapter, COMAR 10.09.01 Advanced Practice Nurse Services, Regulations .01—.11 under COMAR 10.09.21 Nurse Midwife Services, and Regulations .01—.10 under COMAR 10.09.39 Nurse Anesthetist Services, which was published in 43:26 Md. R. 1462—1464 (December 23, 2016).
    Statement of Purpose
    The purpose of this action is to adopt new streamlined regulations pertaining to advanced practice nurses under one chapter. This proposal addresses stakeholder concerns by referencing the regulations that require the supervision of nurse anesthetist services by a physician, removing a limitation on the number of visits per day, and removing certain definitions.
    Comparison to Federal Standards
    There is no corresponding federal standard to this proposed action.
    Estimate of Economic Impact
    The proposed action has no economic impact.
    Economic Impact on Small Businesses
    The proposed action has minimal or no economic impact on small businesses.
    Impact on Individuals with Disabilities
    The proposed action has no impact on individuals with disabilities.
    Opportunity for Public Comment
    Comments may be sent to Michele Phinney, Director, Office of Regulation and Policy Coordination, Department of Health and Mental Hygiene, 201 West Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499 (TTY 800-735-2258), or email to dhmh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through June 26, 2017. A public hearing has not been scheduled.
    10.09.01 Advanced Practice Nurse Services
    Authority: Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland
    .01 Definitions.
    A. In this chapter, the following terms have the meanings indicated.
    B. Terms Defined.
    (1) “Advanced practice nurse” means a:
    (a) Certified nurse practitioner;
    (b) Certified nurse midwife; or
    (c) Certified registered nurse anesthetist.
    (2) 'Board' means the Maryland State Board of Nursing.
    (3) 'Certified nurse midwife (CNM)' means a registered nurse who is:
    (a) Certified by the Board to practice nurse midwifery under COMAR 10.27.05;
    (b) Certified by the American College of Nurse-Midwives; or
    (c) Certified by the American Midwifery Certification Board.
    (4) 'Certified nurse practitioner' means:
    (a) A registered nurse who, by reason of certification under COMAR 10.27.07, may practice in Maryland as a nurse practitioner under the terms of that chapter; or
    (b) If out-of-State, a registered nurse who qualifies as a nurse practitioner in the state in which services are provided.
    (5) 'Certified registered nurse anesthetist (CRNA)' means a registered nurse who is certified to practice nurse anesthesia by the Board under COMAR 10.27.06.
    (6) 'Department' means the Department of Health and Mental Hygiene, as defined in COMAR
    (7) “Medicare” means the insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq.
    (8) “Participant” means an individual who is certified as eligible for and is receiving Medical Assistance benefits.
    (9) 'Physician' means an individual who meets the licensure requirements and conditions of participation of COMAR 10.09.02. 
    (10) 'Program' means the Maryland Medical Assistance Program.
    (11) 'Provider' means an advanced practice nurse who, through appropriate agreement with the Department, has been identified as a Program provider by the issuance of a provider number.
    .02 License and Certification Requirements.
    A. The provider shall:
    (1) Meet all license requirements as set forth in COMAR; and
    (2) Be licensed and hold all certifications as required by the Board.
    B. If practicing out-of-State, the provider shall meet the regulatory requirements of the state in which the services are provided.
    .03 Conditions for Participation.
    A. A provider shall meet all conditions for participation as set forth in COMAR
    B. An advanced practice nurse may not knowingly employ or contract with a person, partnership or corporation which the Program has disqualified from providing or supplying services to Program participants.
    .04 Covered Services.
    A. Subject to §B of this regulation, the Program covers medically necessary services rendered to participants as follows:
    (1) For nurse practitioners:
    (a) Medically necessary services within the provider’s scope of practice as described in COMAR 10.27.07; or
    (b) If out-of-State, nurse practitioner services authorized in the state in which the services are provided;
    (2) For nurse midwives:
    (a) Medically necessary services within the provider’s scope of practice as described in COMAR 10.27.05; or
    (b) If out-of-State, nurse midwife services authorized in the state in which the services are provided;
    (3) For certified registered nurse anesthetists:
    (a) Medically necessary services within the provider’s scope of practice and in collaboration with an authorized provider as described in COMAR 10.27.06; or
    (b) If out-of-State, certified registered nurse anesthetist services authorized in the state in which the services are provided;
    (4) Laboratory services when the advanced practice nurse is not required to register their office as a medical laboratory pursuant to Health-General Article, Title 17, Subtitle 2, Annotated Code of Maryland; and
    (5) Drugs and supplies within the advanced practice nurse’s scope of practice.
    B. The services in §A of this regulation shall be:
    (1) Medically necessary; and
    (2) Described in the participant’s medical record in sufficient detail to support the invoice submitted for those services.
    .05 Limitations.
    Under this chapter, the Program does not cover the following:
    A. Services not medically necessary;
    B. Services prohibited by the Maryland Nurse Practice Act or by the Board;
    C. Advanced practice nursing services included as part of the cost of:
    (1) An inpatient facility;
    (2) A hospital outpatient department; or
    (3) A freestanding clinic;
    D. Visits by or to the provider solely for the purpose of the following:
    (1) Prescription, drug, or food supplement pick-up;
    (2) Recording of an electrocardiogram;
    (3) Ascertaining the patient’s weight;
    (4) Interpretation of laboratory tests or panels; or
    (5) Prescribing or administering medication;
    E. Drugs and supplies which are acquired by the provider at no cost;
    F. Injections and visits solely for the administration of injections, unless medical necessity and the patient's inability to take oral medications are documented in the patient's medical record;
    G. Services paid under the free-standing dialysis program as described in COMAR 10.09.22;
    H. Immunizations required for travel outside the continental United States;
    I. Prescriptions and injections for central nervous system stimulants and anorectic agents when used for weight control;
    J. Acupuncture;
    K. Hypnosis;
    L. Travel expenses;
    M. Investigational or experimental drugs and procedures; 
    N. Services denied by Medicare as not medically justified;
    O. Specimen collection, except by venipuncture and capillary or arterial puncture, as a separate service;
    P. Laboratory or X-ray services performed by another facility, which shall be billed to the Program directly by the facility; and
    Q. For certified nurse midwives, a separate visit charge on date of delivery.
    .06 Payment Procedures.
    A. The provider shall submit the request for payment in the format designated by the Department.
    B. The Department reserves the right to return to the provider, before payment, all requests for payment not properly completed.
    C. The provider shall charge the Program the provider’s:
    (1) Customary charge to the general public for similar services; and
    (2) Acquisition cost for injectable drugs or dispensed medical supplies.
    D. The provider shall be paid the lesser of:
    (1) The provider’s customary charge to the general public unless the service is free to individuals not covered by the Program; or
    (2) The Program rates as described in COMAR
    E. If a service is free to individuals not covered by the Program:
    (1) The provider:
    (a) May charge the Program; and
    (b) Shall be reimbursed in accordance with §D of this regulation; and
    (2) The provider’s reimbursement is not limited to the provider’s customary charge.
    F. Payments on Medicare claims are authorized, if:
    (1) Services are covered by the Program;
    (2) The provider accepts Medicare assignments;
    (3) Medicare makes direct payment to the provider;
    (4) Medicare has determined that services were medically justified; and
    (5) Initial billing is made directly to Medicare according to Medicare guidelines.
    G. The Department shall make supplemental payments on Medicare claims subject to the following provisions:
    (1) Deductible insurance shall be paid in full; and
    (2) Coinsurance shall be paid at the lesser of:
    (a) 100 percent of the coinsurance amount; or
    (b) The balance remaining after the Medicare payment is subtracted from the Program rate.
    H. The provider may not bill the Program for:
    (1) Completion of forms and reports;
    (2) Broken or missed appointments; or
    (3) Professional services rendered by mail or telephone.
    I. The Program may not make direct payment to recipients.
    J. Billing time limitations for claims submitted pursuant to this chapter are set forth in COMAR 10.09.36.
    K. The Program shall reimburse for all medical laboratory services according to the fees established under COMAR 10.09.09.
    L. An advanced practice nurse who is employed by or under contract to any physician, clinic, or hospital may not bill for any service for which reimbursement is sought by the physician, clinic, or hospital.
    M. The Program may not reimburse nurse midwives for prenatal or postpartum care once the patient has been referred to a physician for completion of prenatal or postpartum care.
    .07 Recovery and Reimbursement.
    Recovery and reimbursement are as set forth in COMAR
    .08 Causes for Suspension or Removal and Imposition of Sanctions.
    Causes for suspension or removal and imposition of sanctions are as set forth in COMAR
    Secretary of Health and Mental Hygiene