The department shall create by rule a community-based system in which a medically indigent patient may be referred to a medical home upon discharge from hospital. The medical home shall provide ongoing primary and preventive care and case management with periodic reports to the department regarding the medically indigent patient's health status and participation in the patient's treatment plan. Appropriate reimbursement to the medical home provider for patient primary and preventive care services employing utilization management and case management shall be coordinated by the department.
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