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Florida Gov. Charlie Crist didn't establish a specific enrollment goal for Cover Florida, the state's unsubsidized private insurance program for the uninsured, when he announced the start of enrollment in January 2009. But in a state with approximately 3.8 million uninsured adults, the fact that only 5,246 people signed up for one of the 27 plans in the program's first 11 months appears to have defied all expectations.

Crist and others championed Cover Florida in 2008 as a low-cost private insurance program to fill a gap in the insurance market. The plans are designed for Florida adults who don't qualify for public programs and who have been uninsured for at least six months. Adults become eligible more quickly if they lose coverage because of a divorce, job loss or spouse's death. The plans also are portable.

"When we passed it, everybody was high-fiving themselves," said Rep. Ed Homan, MD, an assistant professor of orthopedic surgery at the University of South Florida College of Medicine.

But Cover Florida plans' sign-up rate has been severely hindered by a lack of public awareness, limited benefits and the plans' small sales commissions compared with other plans, insurance underwriters said.

Cover Florida plans cost as little as $50 a month, but their coverage is less comprehensive than many individual market plans that cost just a little more, said Steve Israel, spokesman for the Florida Assn. of Health Underwriters. "I've sold about half a dozen of them. And I sell them only as 'better than nothing.' "

Cover Florida premiums also vary by age, gender and home address.

Six health insurance companies offer Cover Florida plans, including two firms offering statewide plans. The authorizing legislation instructed participating insurers to offer at least two types of plans: one with catastrophic and emergency department coverage, and one without. The latter, "preventive" plan generally has less costly premiums than the catastrophic plans. But 82% of subscribers picked catastrophic plans.

Cover Florida offers several coverage options, but the main difference with other plans is that people with preexisting conditions are eligible for Cover Florida, said Dale Maloney, co-chair of the Florida Assn. of Health Underwriters' legislative committee.

Plan subscribers, however, must wait 12 months before their preexisting conditions are covered. Also, insurers balance the risk of covering such conditions by setting benefit limits as low as $25,000 each year and $50,000 in a lifetime for catastrophic plans, for example.

A year is a long time to wait, said Erin Moaratty, chief special projects officer at Patient Advocate Foundation, which counsels people with chronic conditions on their health coverage options. "Most people who reach out to our foundation, they're looking for something that's going to cover them almost immediately."

Also, commissions for selling Cover Florida plans don't compare with those offered by standard private plans, Dr. Homan said. Israel said Cover Florida might offer underwriters a single $25 fee for each sale, compared with the standard rate of 20% of premiums for the first year.

More important, Israel said, the Cover Florida legislation did not include any funding for an advertising or public awareness campaign. Israel said this is one of the main reasons enrollment has been low.

Some stakeholders had little to say about Cover Florida and its enrollment. The Florida Medical Assn. has no comment, according to FMA spokeswoman Erin VanSickle.

United HealthGroup -- one of the two companies offering statewide Cover Florida plans -- does not know why plan enrollment has been low, said spokesman Roger Rollman.

Blue Cross and Blue Shield of Florida -- the other company offering a statewide plan -- directed questions to the state. Crist's office deferred to the Florida Agency for Healthcare Administration, the state agency administering Cover Florida.

AHCA spokeswoman Shelisha C. Durden said the agency doesn't believe the Cover Florida plans need to be adjusted. Enrollment "is remarkable given the lack of funding to market and promote the plans. [AHCA] is renewing its efforts to spread the word to uninsured Floridians," Durden said in an e-mail.

Moaratty said Cover Florida plans are better than not having an option at all but that they need to be less limited to be more helpful. Moaratty and Maloney suggested covering more of Florida's uninsured by re-opening the state's high-risk insurance pool, which was frozen in the early 1990s.

Dr. Homan is also chair of the Florida House Health Policy Council, which held hearings on Medicaid reform late last year. He would like to provide more coverage to the uninsured by allowing people to buy into Medicaid coverage. This move would be accomplished through a provision in a bill he's backing to create Medicaid medical homes.

The print version of this content appeared in the Feb 8, 2010 issue of American Medical News.

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