California Code, Welfare and Institutions Code - WIC § 15905

(a) A description of the proposed Health Care Coverage program, including, but not limited to, all of the following:

(b) A description of the quality monitoring system to be implemented with the Health Care Coverage program.

(c) A description of the population to be served.

(d) A list of health care providers who have agreed to participate in the Health Care Coverage program.

(e) A description of the organized health care delivery systems to be used for the Health Care Coverage program, including, but not limited to, designation of a medical home and processes used to assign eligible individuals to a primary care provider.

(f) A list of the health benefits to be provided, including the preventive and primary care services and how they will be promoted.

(g) A description of the care management services to be provided, and the providers of those services.

(h) A calculation of the average cost per individual served.

(i) The number of individuals to be served.

(j) The mechanism under which the proposed Health Care Coverage Initiative will make expenditures to, or on behalf of, providers and other entities, including, but not limited to, documentation to support the ability to implement the Health Care Coverage program by September 1, 2007, and to claim the full amount of the allocation for each program year.

(k) A description of the source of the local nonfederal share of funds.

(l) A description of how the proposed Health Care Coverage program will strengthen the local health care safety net system.

(m) A consent form signed by the applicant to provide requested data elements as required per the Special Terms and Conditions of California's Section 1115 Medicaid demonstration project waiver number 11-W-00193/9 relating to hospital financing and health coverage expansion.

(n) Use of a reliable medical record system, that may include, but need not be limited to, existing electronic medical records.

(o) A complete description of health care services currently provided to Medi-Cal beneficiaries and a description as to how the proposed Health Care Coverage program will coordinate its Health Care Coverage program with services provided to Medi-Cal beneficiaries.