112 [81 Op. Att’y

LICENSES

HEALTH OCCUPATIONS ) STATUTORY CONSTRUCTION )

CERTIFICATION PROCEDURE FOR EMERGENCY MEDICAL

SERVICES PROVIDERS IS GENERALLY TANTAMOUNT TO

LICENSING REGIME

June 12, 1996

Robert R. Bass, M.D., FACEP

Executive Director

Maryland Institute for Emergency

 Medical Services Systems

You have requested our opinion whether the term “license,” as

used in proposed legislation to authorize and regulate the practice of

emergency medical services providers, would be equivalent to the

current term “certify.”

Our opinion is as follows: The current regulatory regime for

emergency medical services providers, although using the term

“certify,” is generally tantamount to a licensing regime.

Accordingly, with one exception, the use of the term “license” in

new legislation would not signify any substantive change. The one

exception is that statutory “licensure” of Emergency Medical

Technicians-Ambulance, Emergency Medical Technicians-Basic,

and First Responders would contain a prohibition on unauthorized

practice not found in current law. 

I

Background

There are five categories of emergency medical services

providers within the regulatory purview of the Maryland Institute of

Emergency Medical Services Systems (“MIEMSS”) and the Board

of Physician Quality Assurance (the “Board”):
Gen. 112] 113

1 EMT-As and EMT-Bs are essentially the same level. EMT-B is

the national standard, established by the National Highway Safety

Administration, for the basic level of emergency medical services.

However, EMT-B does have a somewhat more expansive scope of

practice. An EMT-B may assist in administering medication and operate

an Automatic External Defibrillator, a shocking device used in the event

of a cardiac incident. EMT-B has been adopted by Maryland with some

modifications and is currently in the pilot phase. It will eventually replace

the EMT-A category. 

1. First Responders, who are regulated solely by MIEMSS;

2. Emergency Medical Technicians ) Ambulance (“EMTAs”), who are regulated solely by MIEMSS;

3. Emergency Medical Technicians ) Basic (“EMT-Bs”),

who are also regulated solely by MIEMSS;1

4. Cardiac Rescue Technicians (“CRTs”), who are regulated

by the Board in conjunction with MIEMSS; and 

5. Emergency Medical Technicians ) Paramedics (“EMTPs” or paramedics”), who are also regulated by the Board in

conjunction with MIEMSS. 

These various titles represent a progression in knowledge and skills:

from First Responder, which is a program designed for law

enforcement, fire department, and other public safety personnel,

who, with limited equipment, may be called on to provide initial

assessment and intervention; through EMT-P, which involves the

delegated practice of medicine, including invasive procedures like

endotracheal intubation and cardiac defibrillation. 

The division of the authority to regulate emergency medical

services providers parallels a traditional division of the providers

into two groups, Basic Life Support and Advanced Life Support.

MIEMSS alone has regulated Basic Life Support personnel. See

§13-1D-10(5) of the Education Article, Maryland Code (authorizing

the Executive Director of MIEMSS to “[c]oordinate the training of

all personnel in the Emergency Medical Services System and

develop the necessary standards for their certification”). Because

Advance Life Support involves activities that fall within the practice

of medicine, the Board has regulated these providers.
114 [81 Op. Att’y

The Board and MIEMSS are contemplating legislation that

would transfer the authority to regulate EMT-Ps and CRTs to

MIEMSS, thereby consolidating the regulation of emergency

medical services providers in one State agency. Such departmental

legislation was introduced as House Bill 1052 in the 1996 legislative

session, but the bill was withdrawn prior to its hearing. Your

question is whether the proposed legislation, which we shall assume

to be substantively the same as House Bill 1052, would bring about

a change in the status of these providers if the legislation were to

authorize MIEMSS to “license” them, instead of “certifying” them,

as under the current practice. 

II

The Characteristics of a “Licensing” Regulatory Regime

“Historically, there has been no consistent usage of the terms

licensure, certification or registration in the Maryland Code or in

case law generally.” Letter from Assistant Attorney General Kathryn

M. Rowe to Senator Barbara A. Hoffman (March 7, 1989).

Attempting to end this potential source of confusion, the Department

of Legislative Reference has sought in recent years to establish

consistent usage. For example, a model drafting guide from 1988

states that the term “license” is “the only term to be used to denote

the privilege or right to practice that a State board issues.”

Department of Legislative Reference, Model Guide for Drafting

Governmental Units and Licensing Provisions 14 (Staff Draft 1988).

Likewise, the General Revisor’s Note to the Business Occupations

Article, written in 1989, uses the term “license” to mean “an

authorization to practice a particular occupation that a person who

is not licensed in that occupation may not practice.” Chapter 3 of

the Laws of Maryland 1989 at 833.

An elaboration of this meaning of “licensure” was set out in an

August 12, 1985 advice letter written by Assistant Attorney General

Robert Zarnoch. Mr. Zarnoch observed that “a true licensing

scheme will ordinarily regulate someone’s right to practice a certain

business or profession, define what constitutes such practice,

establish an agency to monitor it and provide detailed and specific

grounds for acquisition and loss of such a license.”
Gen. 112] 115

A more recent advice letter summarized the key characteristics

of a licensing scheme as follows: 

(1) delineation of the qualifications for

entering the profession;

(2) provision for review of the

applicant’s qualifications by a State agency;

(3) prohibition against those without

the specific credential practicing the

profession; 

(4) identification of the scope of

practice of the profession; [and]

(5) establishment of disciplinary

standards for those who practice the

profession.

Advice letter from Assistant Attorney General Jack Schwartz to

Senator Paula C. Hollinger (January 23, 1996). 

By contrast, the term “certification” has come to be used to

denote a lesser degree of regulation, lacking some of the key

characteristics of licensing. “[T]he terms ‘certification’ and

‘certified’ are used to indicate an official recognition of a person as

a qualified practitioner and an accompanying grant of the exclusive

privilege or right to make certain representations.” General

Revisor’s Note to the Business Regulation Article.

In a recent case, Reisch v. State, 107 Md. App. 464, 668 A.2d

970 (1995), the Court of Special Appeals likewise drew a distinction

between a certificate in lead abatement and a license issued to a

professional, such as a plumber, electrician, or architect, who is

required to meet certain standards of competence or experience as a

prerequisite to engaging in that profession. 107 Md. at 473-74.

Pursuant to regulation, lead paint abatement workers are required to

take a course approved by the Maryland Department of the

Environment, consisting of at least six hours, once every five years.

The instructor issues the certificate after the completion of the

course. A list of students completing the course is provided to the

Department of the Environment, which then makes the information
116 [81 Op. Att’y

available to the public. There are no provisions for disciplinary

standards, decertification, or any review of applicants by the agency.

Nevertheless, despite this growing body of material seeking to

denote substantive differences through use of the terms “license” and

“certification,” neither of these terms has intrinsic significance. As

Ms. Rowe pointed out in her 1989 advice letter to Senator Hoffman,

“the degree of regulation is determined by the provisions of the

statute, not by the terminology chosen.” For example, in that letter

Ms. Rowe concluded that, although the Maryland Youth Camp Act

used the term “certification,” in substance it was a licensing statute.

Similarly, the 1996 advice letter to Senator Hollinger determined

that, although the regulatory regime for respiratory care practitioners

is labeled “certification,” it has all the essential elements of a

“licensing” statute.

III

The Characteristics of the “Certification” 

Regulatory Regime for Emergency Medical Services Providers

In this part of the opinion, we shall assess whether the current

regulatory regime for “certified” emergency medical services

providers is substantively similar to a licensing regime. If so, then

legislation to “license” these providers would not effect a substantive

change.

A. EMT-Ps and CRTs

1. Qualifications.

COMAR 10.32.08.03 delineates the qualifications for all

applicants to EMT-P training programs; COMAR 10.32.08.05

delineates the qualifications for EMT-P certification. Similarly,

COMAR 10.32.06.02 delineates the qualifications for applicants to

CRT training programs; COMAR 10.32.06.05 delineates the

qualifications for CRT certification. 
Gen. 112] 117

2 The term “practice medicine” includes “treating ... any physical

... ailment ... [b]y appliance, ... drug, ... or treatment.” HO §14-101(k)(2).

2. Review of applications.

COMAR 10.32.08.05(C) provides that the Board is to act upon

the EMT-P applicant’s submission and approve that application if

the certification requirements have been met. COMAR

10.32.06.05(C) provides the same for CRTs. 

3. Unauthorized practice.

Under §§14-301 and 14-601 of the Health Occupations (“HO”)

Article, no one may practice medicine without a license issued by

the Board, except as otherwise provided for in the Maryland Medical

Practice Act. Essentially, HO §§14-303 and 14-305 provide

exceptions for CRTs and EMT-Ps. They may perform limited

activities, subject to the authority of the Board, that would otherwise

be considered the practice of medicine and therefore could only be

performed by a licensed physician.2 In other words, a nonphysician

who is not certified as required by HO §§14-303 and 14-305 and

who does what a CRT or EMT-P does would be practicing medicine

without a license.

4. Scope of practice.

The scope of practice for both CRTs and EMT-Ps is delimited

in both the Medical Practice Act and implementing regulations. HO

§14-303 provides that, subject to the authority of the Board, a CRT

may perform all phases of cardiopulmonary resuscitation, administer

drugs or intravenous solutions as directed by a licensed physician,

and obtain blood for laboratory analysis. HO §14-305 provides that,

subject to the authority of the Board, an EMT-P may perform all

phases of cardiopulmonary resuscitation, all phases of prehospital

life support, administer drugs and intravenous solutions as directed

by a licensed physician, and obtain blood for laboratory analysis.

Additionally, MIEMSS and the Board have issued extensive medical

protocols that all CRTs and EMT-Ps are required to follow. Acting

beyond this authorized scope of practice is a ground for discipline.

COMAR 10.32.08.12 and 10.31.06.02. 
118 [81 Op. Att’y

5. Disciplinary standards.

HO §14-303(c) provides for the discipline of CRTs. HO §14-

305(e) provides for the discipline of EMT-Ps. Additionally, the

grounds for disciplinary action and the procedures to be followed are

set out in substantial detail in the regulations for each program. 

B. First Responders, EMT-As, and EMT-Bs

1. Qualifications.

MIEMSS has specified detailed qualifications for certification

in the EMT-A, EMT-B, and First Responder programs in testing and

certification policies for each group of providers. 

2. Review of applications.

The EMT-A, EMT-B, and First Responder testing and

certification policies provide that applicants must submit verification

of their successful completion of a MIEMSS-approved course prior

to being tested for certification. MIEMSS administers the test and

issues the certification upon a determination that the applicant has

passed.

3. Unauthorized practice.

An EMT-A is defined at COMAR 10.32.08.01B(5) as “an

individual who has been tested and certified by MIEMSS to provide

basic life support.” As we understand it, basic life support )

encompassing such actions as cardiopulmonary resuscitation, airway

management, and control of bleeding ) has not been considered by

the Board to be the practice of medicine. Therefore, the lack of

certification has no effect on anyone’s prerogative to perform these

actions.

4. Scope of practice.

The EMT-A, EMT-B, and First Responder skills are set out in

course objectives, program standards, and protocols issued by

MIEMSS. The MIEMSS testing and certification policies for each

of those programs state that EMT-As, EMT-Bs, and First

Responders may only practice the skills taught in a MIEMSSapproved course. The policies further provide that the performance
Gen. 112] 119

3 We note that, as a matter of practice, the Board has historically

reserved the term “license” for the physicians that it regulates. Other

health professionals regulated by the Board, such as acupuncturists, have

been “certified” or “registered.” In 1994 a separate Acupuncture Board

was created to “license” acupuncturists who were previously “registered”

by the Board. HO Title 1A, the Maryland Acupuncture Act. There was

no substantive change between the registration regime and the licensing

regime.

of any medical act not specified by MIEMSS is grounds for

decertification.

5. Disciplinary standards.

The testing and certification policies for EMT-As, EMT-Bs,

and First Responders provide for the discipline of each of those

levels of providers and set out specific grounds for decertification as

well as the procedures to be followed.

C. Conclusion

 In our view, the current “certification” regime for CRTs and

EMT-Ps contains every essential characteristic of a “licensing”

regime and serves the same function: to provide minimum standards

for the training and approval of these providers and to protect the

public from unqualified emergency medical services providers. The

proposed legislation also contains the same essential characteristics

of a licensing regime. If, as a result of legislation, these providers

hold a “license,” instead of a certificate, they will have no greater

(or lesser) authority to function than they do today. The boundaries

of their activities, as well as the degree of State authority, are

determined by the provisions of the statute and implementing

regulations and policies, not the terminology chosen. However,

given current drafting practice, “licensure” is undoubtedly the better

term to describe the current status of CRTs and EMT-Ps.3

The same is largely true of EMT-As, EMT-Bs, and First

Responders, with one notable exception: Unlike the current

situation, those without the requisite background and MIEMSS

approval would be prohibited, under the proposed legislation, from
120 [81 Op. Att’y

4 Under House Bill 1052, with some exceptions, unlicensed

individuals would have been prohibited from providing “out-of-hospital

emergency services.”

providing services within the scope of practice of these providers.4

Thus, under the proposed legislation, “licensure” is indeed the better

term to describe the regulatory regime for EMT-As, EMT-Bs, and

First Responders; but in this instance “licensure” signifies a

broadening of the regulatory regime from that under current law )

not the term itself, but the underlying substance.

IV

Conclusion

In summary, it is our opinion that the current statutory and

regulatory regime for the authorization and regulation of emergency

medical services providers, although using the term “certify,” is in

all substantive respects a licensing regime (except for the omission

of an unauthorized practice provision relating to EMT-As, EMT-Bs,

and First Responders). Accordingly, with that one exception,

proposed legislation would effect no substantive change in the

authority or regulation of emergency medical service providers if, in

accordance with current drafting practice, the term “license” were

used. 

 J. Joseph Curran, Jr.

 Attorney General

Jack Schwartz

Chief Counsel

Opinions and Advice

Editor’s Note:

Legislation similar to that discussed in Part I above was

enacted as Chapter 201 of the Laws of Maryland 1997.