What employers and other organizations need to know now to get ready to succeed

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1 What employers and other organizations need to know now to get ready to succeed

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3 Health Reform Survival Guide In March 2010, the President signed into law the Patient Protection and Affordable Care Act (PPACA). This act puts in place a variety of health insurance reforms designed to improve the American healthcare delivery system. To help employers and other organizations prepare for the new reform requirements, we assembled this Health Reform Survival Guide. Inside you will find information to help you understand the ins and outs of health reform and how they affect your business, as well as recommended actions so you know what steps to take moving forward. Preface Our Guide begins with provisions starting in 2010 and continues year by year through You will also notice a gap in reform provisions between 2015 and Although there are actions taking place, we decided to omit them because they did not directly affect employers. In addition, you will find a glossary at the back of the Guide to help explain some of the terms mentioned in the provisions. While we made the best possible effort to provide the most accurate and up-to-date information about health reform and the Patient Protection and Affordable Care Act, provisions and policies are always changing. We recommend that you regularly visit the resources listed in this Guide to access the most up-to-date and accurate information. You can also find additional information on our website at: HealthAdvocate.com or HealthcareSurvivalGuide.com. We hope you find our Health Reform Survival Guide informative and helpful. If you have any questions, please feel free to contact us. Health Reform Survival Guide i

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5 Health Reform Survival Guide Table of Contents Preface... i Health Reform Timeline Glossary Resources Health Reform Survival Guide ii

6 Health Reform Timeline Dependent children covered up to age 26 Small businesses receive tax credits Pre-existing Condition Insurance Plan Consumer insurance protections Provide free preventive care Provide external appeals process Early Retiree Reinsurance Program HealthCare.gov created Medicare prescription drug rebates Additional preventive services for women Comparative clinical effectiveness research fee Data collection about health disparities Quality reporting Uniform notice of material change PAGE 3 PAGE 5 PAGE 6 Disclosure of Minimum Medical Loss Ratio Medicare doughnut hole discounts Reimbursement restrictions for OTC drugs Benefits disclosure Wellness program grants Tax on Health Savings Accounts 1 Health Reform Survival Guide

7 Change to waiting periods Health insurance required Employer penalties start Benefits package standards Health insurance exchanges open Premium subsidies Everyone guaranteed coverage Employer Reporting Requirements Medicaid expansion Wellness program rewards No annual limits on coverage * 2016 * 2017 * 2018 PAGE 8 PAGE 9 PAGE 12 Contributions limited to Flexible Spending Accounts State notification about exchange participation Tax on Cadillac health plans Medicare tax increase Employer retiree coverage subsidy CO-OP Health Insurance Plans *Actions taking place in years were omitted because they do not directly affect employers. Health Reform Survival Guide 2

8 2010 Dependent children covered up to age 26 Children up to age 26 can stay on their parents individual or group health policies. Action: Communicate coverage for young adults up to age 26 with employees. Need to Know Information Possible Savings Compliance Penalties Share Information Small businesses receive tax credits Small businesses, with fewer than 25 employees and average wages under $50,000, that offer healthcare benefits and contribute at least 50 percent of the premium costs for two years, will receive tax credits. Phase 1 ( ): tax credit up to 35% (25% for non-profits) of employer cost; Phase 2 (2014 and later): tax credit up to 50% (35% for non-profits) of employer cost if purchased through an Insurance Exchange for two years. The credit rises to 50% of their premium costs in Action: Confirm small business tax credits were taken with your 2010 tax filings. Pre-existing Condition Insurance Plan (PCIP) People who have been uninsured for at least six months and who have a pre-existing condition will have access to affordable insurance through a temporary, Pre-existing Condition Insurance Plan in their state. The federal government is operating programs in 23 states and the District of Columbia, while the remaining states are running their own programs. For more information: pcip.gov Action: Familiarize yourself with your state s PCIP program. Advise eligible employees. Consumer insurance protections Insurance companies (individual and group policies) will be banned from rescinding people s coverage when they become ill, from denying children coverage based on pre-existing medical conditions or from including pre-existing condition exclusions for children, and from imposing lifetime caps on coverage. Annual limits on benefits will be eliminated by Some grandfathered plans are exempt. Action: Review your health policies for consumer protection compliance. Communicate changes with your employees. 3 Health Reform Survival Guide

9 2010 Provide free preventive care All new group and individual health plans are required to provide free preventive care, including immunizations, preventive care for infants, children, and adolescents, and additional preventive care and screenings for women. Some grandfathered plans are exempt. Action: Make your employees aware that preventive care is now covered and encourage them to take advantage of the services. Provide external appeals process New insurance plans are now required to provide an effective external process for allowing consumers to appeal health plan decisions. Action: Share external appeals process with employees. Early Retiree Reinsurance Program (ERRP) Provides reimbursement to participating employment-based plans for a portion of the costs of health benefits for early retirees and early retirees spouses, surviving spouses, and dependents. It was set up to help offset the cost of expensive premiums for employers providing coverage to retirees over age 55 who are not eligible for Medicare. Five billion dollars was appropriated for the fund. Action: For more information visit errp.gov HealthCare.gov created The Department of Health and Human Services (HHS) has developed an internet website to help residents identify health coverage options: HealthCare.gov Action: Tell your employees about the new HealthCare.gov website. Medicare prescription drug rebates In 2010, a one-time $250 rebate was given to Medicare beneficiaries who reached the Part D coverage gap. Drug companies will be lowering the prices on their brandname drugs by 50% starting in 2011 and by 75% in 2020, which will completely close the doughnut hole so the rebate will no longer be needed. Action: No action needed. Medicare will contact seniors directly about their $250 rebate. Health Reform Survival Guide 4

10 2011 Need to Know Information Possible Savings Compliance Penalties Share Information Health plans disclose Minimum Medical Loss Ratio (MLR) Requires health plans to report the proportion of premium dollars spent on clinical services, quality and other costs. Rebates must then be provided to consumers if the share of the premium spent on clinical services and quality is less than 85% for plans in the large group market and 80% for plans in the individual and small group markets. Health plans were required to report MLR in Rebates started being distributed in January Action: Contact your insurer to request more information about their reported Minimum Medical Loss Ratio to the federal government and if you or your employees are eligible for a rebate. Medicare doughnut hole discounts Starting January 1, 2011, Medicare beneficiaries with Part D prescription drug coverage will receive 50% discounts on all brand-name drugs from drug manufacturers to help close the doughnut hole. Federal subsidies will also be phased in to cover generic drugs. By 2020, the doughnut hole coverage gap will be closed. Action: Remind retirees who qualify for Medicare that they should receive a discount when they purchase their medication. Reimbursement restrictions for OTC drugs Over-the-counter drugs, not prescribed by a doctor, will no longer be reimbursable through health reimbursement arrangements, Flexible Spending Accounts, or on a tax-free basis in Health Savings Accounts or the Archer Medical Savings Account. Employers must make this clear to employees already enrolled in these types of programs. They should also communicate this to employees during open enrollment or when they sign up for their health benefits. Action: Inform employees of the reimbursement restrictions for OTC drugs. 5 Health Reform Survival Guide

11 2011 Benefit disclosure Employers will be required to disclose the value of benefits provided for each employee s health insurance coverage on the employee s W-2 form. This is optional in 2011, but required in For more information visit: irs.gov and click on Affordable Care Act Tax Provisions. Action: Confirm that your payroll software/process reports the value of employee health benefits. Wellness program grants Provides grants for up to five years to small employers that establish wellness programs. There are requirements about what the employer must offer to qualify, and employers must submit an application the U.S. Department of Health and Human Services to be considered. Visit to apply. Action: Apply for federal grants to establish a wellness program. Tax on Health Savings Accounts (HSAs) The tax on distributions from an HSA or Archer MSA that are not used for qualified medical expenses is raised to 20%. Action: Communicate Health Savings Account taxing changes to employees Additional preventive services offered to women New private health plans must cover women s preventive services with no cost sharing in plan years starting on or after August 1, In addition to regulations already in place for coverage of cervical cancer screenings and mammograms, other services such as well-women visits, gestational diabetes screening, HPV testing, STI counseling, contraception counseling, breastfeeding support/supplies, and domestic violence screening will now be covered. Action: Check with your insurer to make sure they are prepared to comply. Notify your employees. Visit HealthCare.gov for more information. Health Reform Survival Guide 6

12 2012 Need to Know Information Possible Savings Compliance Penalties Share Information Comparative clinical effectiveness research fee This fee will be imposed on both self- and fully-insured plans and will go to fund the Patient-Centered Outcomes Research Institute which will analyze the effectiveness of treatments, services, procedures, medications, etc. Fees apply to policy or plan years ending after September 30, 2012, and will vary based on the plan year ending dates. Self-insured plans will pay directly while fully-insured plans may build the fee into their pricing. Action: Fully-insured employers should contact their insurance plan to ask about cost. Self-insured employees should visit hhs.gov to learn more. Data collection about health disparities Any federally conducted or supported health program, activity or survey will be required to collect and report data on race, ethnicity, gender, primary language and disability status. The HHS Secretary will then analyze the data for trends in health disparities at the state and federal levels and publish the data and findings online. The data will also help to determine the effect of health reform on the population. Employers should stay informed by visiting HealthCare.gov and signing up to receive updates. Action: Data collection by the federal government may worry some employees. Stay on top of the developments so you can put employees at ease. Quality of care/cost reporting Health insurance issuers and Group Health Plans are required to provide a report to HHS, as well as to plan enrollees, about any plan benefits, costs or designs that provide incentives used in certain cost-reduction strategies. Effective for plan years beginning after March 23, 2012 (non-grandfathered plans only). Action: Notify employees that this information will be shared with them. Uniform summary of benefits/notice of material change A uniform summary of benefits and coverage must be provided to all employees and new enrollees by plan sponsors of self-insured plans and health insurance issuers. In addition, 60-day advance notice of any material modifications will be required. Effective no later than March, 23, 2012, however, may be delayed until regulations are issued. Action: If you are self-funded, make sure your materials follow regulations (once issued). If you are fully-insured, check with your insurance provider about their compliance. Explain changes to employees. 7 Health Reform Survival Guide

13 2013 Contributions limited to Flexible Spending Accounts Contributions to Flexible Spending Accounts (FSAs) will be limited to $2,500 a year, indexed to the Consumer Price Index (CPI). Action: Inform employees about spending limits on FSAs. State notification about exchange participation States must notify the Secretary of HHS whether they will operate an American Health Benefit Exchange. Stay informed as to whether your state or the states where your employees reside will be running their own exchange or whether they will default to the federal government. This will prepare you for the 2014 switch to the exchanges. Action: Know the status of your state s insurance exchange. Medicare tax increase Increases in the Medicare Part A (hospital insurance) tax rate on wages by 0.9% (from 1.45% to 2.35%) on earnings over $200,000 for individual taxpayers and $250,000 for married couples filing jointly. Also, a new 3.8 percent tax will apply to unearned income for certain highincome taxpayers. Takes place January 1, Action: Inform your affected employees of the Medicare tax increase. Make sure your payroll deductions are adjusted. Employer retiree coverage subsidy Eliminates the tax deduction for employers who receive Medicare Part D retiree drug subsidy payments. Action: Notify your CPA about the Employer Retiree Coverage Subsidy. CO-OP Health Insurance Plans Creates the Consumer Operated and Oriented Plan (CO-OP) to help foster the creation of non-profit, member-run health insurance companies. CO-OPs must be established by July 1, It is unclear at this time how employers will be affected however, co-ops could be an affordable alternative to private insurance for small employer groups or individuals. For more information, visit: Action: Stay informed about the creation of CO-OP Health Insurance Plans in your area. Health Reform Survival Guide 8

14 2014 Waiting periods Small or large group market plans, including grandfathered health plans, may not impose waiting periods that exceed 90 days. Action: Communicate any changes to your waiting period policy to employees. Need to Know Information Possible Savings Compliance Penalties Share Information Health Insurance required January 1, 2014: Individuals will be required to carry health insurance or pay a penalty. Action: All Americans are now required to have health insurance coverage. Make sure employees understand all their benefit and coverage options. Employer penalties start January 1, 2014: Assesses a fee of $2,000 per full-time employee, excluding the first 30 employees, on employers with more than 50 employees that do not offer coverage, and have at least one full-time employee who receives a premium tax credit. Employers with more than 50 employees that offer coverage, but have at least one full-time employee receiving a premium tax credit, will pay the lesser of $3,000 for each employee receiving a premium credit or $2,000 for each full-time employee, excluding the first 30 employees. Action: Employers could suffer penalties if they don t offer coverage to their employees. Understand your responsibility and plan accordingly. Benefits package standards The Department of Health and Human Services will establish a standard benefits package for policies sold in the exchanges, and individual and small group markets. Consumers will choose different levels of cost-sharing among tiers of plans (bronze, silver, gold and platinum). Action: Communicate standard benefit package details to employees who decide to participate in the exchanges. 9 Health Reform Survival Guide

15 2014 Health insurance exchanges open January 1, 2014: Creates state-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges, administered by a governmental agency or non-profit organization, through which individuals and small businesses with up to 100 employees can purchase qualified coverage. Exchanges will have a single form for applying for health programs, including coverage through the exchanges and Medicaid and CHIP programs. Action: Communicate the details about the state exchanges to employees who decide to participate. Premium and Cost-Sharing subsidies Families with annual incomes between $30,000 and $88,000, that buy plans through the exchanges, receive cost-sharing assistance on a sliding scale. Eligible individuals will receive refundable and advanceable tax credits and cost-sharing subsidies. Premium subsidies are available to families with incomes between 133%-400% of the federal poverty level to purchase insurance through the exchanges, while cost-sharing subsidies are available to individuals purchasing silver level plans through the exchanges with incomes up to 250% of the federal poverty level. Action: Identify those employees who qualify for premium subsidies and explain their options. Everyone guaranteed coverage Requires guarantee issue and renewability of health insurance regardless of health status and allows rating variation based only on age (limited to a 3:1 ratio), geographic area, family composition and tobacco use (limited to a 1.5:1 ratio) in the individual and small group markets and the exchanges. Essentially, insurers will be banned from restricting coverage or basing premiums on health status or gender. Action: Reassure employees that everyone qualifies for coverage, regardless of health status. Health Reform Survival Guide 10

16 2014 Need to Know Information Employer Reporting Requirements January 1, 2014: Large employers must report whether they offer fulltime employees (and their dependents) the opportunity to enroll in minimum essential coverage under an eligible employer-sponsored plan (for plan years starting after December 31st, They must also report the length of the waiting period, the lowest cost option, the employer s share of the total allowed cost option in each of the enrollment categories under the plan and the number and names of employees receiving coverage. Action: Talk to your plan or plan administrator about how to prepare and submit the reports. Possible Savings Compliance Penalties Share Information Medicaid expansion Medicaid eligibility will be expanded to all legal residents with incomes up to 133% of the federal poverty level. Action: Identify low-income employees that they may qualify for Medicaid. Wellness program rewards January 1, 2014: Employers can now offer employees rewards of up to 30%, potentially increasing to 50%, of the cost of coverage for participating in a wellness program and meeting certain health-related standards; establishes 10-state pilot programs to permit participating states to apply similar rewards for participating in wellness programs in the individual market. Action: Encourage employees to participate in your company s wellness program, if you offer rewards. No annual limits on coverage Prohibits insurance companies from placing annual limits on the dollar value of coverage. Action: Review employee benefit materials for any inconsistencies or errors in annual limits. 11 Health Reform Survival Guide

17 Actions taking place in years were omitted because they do not directly affect employers Tax on Cadillac health plans A 40% excise tax will be levied at the insurer level on policies with premiums over $10,200 for individuals or $27,500 for family coverage. Action: Communicate details of excise tax to employees with Cadillac health plans. Health Reform Survival Guide 12

18 Glossary Access: The ability to obtain needed medical care. Access to care is often affected by the availability of insurance, the cost of the care, and the geographic location of providers. Benefit Package: The set of services, such as physician visits, hospitalizations and prescription drugs, that are covered by an insurance policy or health plan. The benefit package will specify any cost-sharing requirements for services, limits on particular services, and annual or lifetime spending limits. Children s Health Insurance Program (CHIP): Enacted in 1997, CHIP is a federal-state program that provides healthcare coverage for uninsured low-income children who are not eligible for Medicaid. States have the option of administering CHIP through their Medicaid programs or through a separate program (or a combination of both). The federal government matches state spending for CHIP, but federal CHIP funds are capped. Co-payment: A fixed dollar amount paid by an individual at the time of receiving a covered healthcare service from a participating provider. The required fee varies by the service provided and by the health plan. Cost-sharing: A feature of health plans where beneficiaries are required to pay a portion of the costs of their care. Examples of costs include co-payments, coinsurance and annual deductibles. Employer Healthcare Tax Credit: An incentive mechanism designed to encourage employers, usually small employers, to offer health insurance to their employees. The tax credit enables employers to deduct an amount, usually a percentage of the contribution they make toward their employees premiums, from the federal taxes they owe. These tax credits are typically refundable so they are available to non-profit organizations that do not pay federal taxes. Employer Mandate: An approach that would require all employers, or at least all employers meeting size or revenue thresholds, to offer health benefits that meet a defined standard, and pay a set portion of the cost of those benefits on behalf of their employees. Entitlement Program: Federal programs, such as Medicare and Medicaid, for which people who meet eligibility criteria have a federal right to benefits. Changes to eligibility criteria and benefits require legislation. The federal government is required to spend the funds necessary to provide benefits for individuals in these programs, unlike discretionary programs for which spending is set by Congress through the appropriations process. Enrollment in these programs cannot be capped and neither states, nor the federal government, may establish waiting lists. Deductible: A feature of health plans in which consumers are responsible for healthcare costs up to a specified dollar amount. After the deductible has been paid, the health insurance plan begins to pay for healthcare services. 13 Health Reform Survival Guide

19 Glossary Federal Poverty Level (FPL): The federal government s working definition of poverty that is used as the reference point to determine the number of people with income below poverty and the income standard for eligibility for public programs. The federal government uses two different definitions of poverty. The U.S. Census poverty threshold is used as the basis for official poverty population statistics, such as the percentage of people living in poverty. The poverty guidelines, released by the U.S. Department of Health and Human Services (HHS), are used to determine eligibility for public programs and subsidies. For 2008, the Census weighted average poverty threshold for a family of four was $22,025 and HHS poverty guideline was $21,200. Grandfathering: Provisions that went into effect on September 23, 2010 required that new benefit standards be made available in all new private health insurance policies. However, plans considered to be grandfathered were exempt from certain requirements as long as employers did not significantly change their benefits. A grandfathered plan is any insurance policy that was purchased and active before the PPACA was signed into law on March 23, For more information, visit: gov/news/factsheets/keeping_the_health_plan_ you_have_grandfathered.html Group Health Insurance: Health insurance that is offered to a group of people, such as employees of a company. The majority of Americans have group health insurance through their employer or their spouse s employer. Healthcare Cooperative (CO-OP): A non-profit, member-run health insurance organization, governed by a board of directors elected by its members. Co-ops provide insurance coverage to individuals and small businesses and can operate at state, regional and national levels. Health Insurance Exchange/Connector: A purchasing arrangement through which insurers offer, and smaller employers and individuals purchase, health insurance. State, regional or national exchanges could be established to set standards for what benefits would be covered, how much insurers could charge, and the rules insurers must follow in order to participate in the insurance market. Individuals and small employers would select their coverage within this organized arrangement. An example of this arrangement is the Commonwealth Connector, created in Massachusetts in Health Savings Account (HSA): A tax-exempt savings account that can be used to pay for current or future qualified medical expenses. Employers may make HSAs available to their employees or individuals can obtain HSAs from most financial institutions. In order to open an HSA, an individual must have health coverage under an HSA-qualified high-deductible health plan. These HSA-qualified high-deductible health plans must have deductibles of at least $1,150 for an individual and $2,300 for a family in Lifetime Benefit Maximum: A cap on the amount of money insurers will pay toward the cost of healthcare services over the lifetime of the insurance policy. Guarantee Issue/Renewal: Requires insurers to offer and renew coverage, without regard to health status, use of services, or pre-existing conditions. This requirement ensures that no one will be denied coverage for any reason. Health Reform Survival Guide 14

20 Glossary Managed Care: A health delivery system that seeks to control access to, and utilization of, healthcare services both to limit healthcare costs and to improve the quality of the care provided. Managed care arrangements typically rely on primary care physicians to act as gatekeepers and manage the care their patients receive. Medicaid: Enacted in 1965 under Title XIX of the Social Security Act, Medicaid is a federal entitlement program that provides health and long-term care coverage to certain categories of low-income Americans. States design their own Medicaid programs within broad federal guidelines. Medicaid plays a key role in the U.S. healthcare system, filling large gaps in the health insurance system, financing long-term care coverage, and helping to sustain the safety-net providers that serve the uninsured. Medical Loss Ratio: The percentage of premium dollars an insurance company spends on medical care, as opposed to administrative costs or profits. Medicare: Enacted in 1965 under Title XVII of the Social Security Act, Medicare is a federal entitlement program that provides health insurance coverage to 45 million people, including people age 65 and older, and younger people with permanent disabilities, end-stage renal disease, and Lou Gehrig s disease. Pre-existing Condition Exclusions: An illness or medical condition for which a person received a diagnosis or treatment within a specified period of time prior to becoming insured. Healthcare providers can exclude benefits for a defined period of time for the treatment of medical conditions that they determine to have existed within a specific period prior to the beginning of coverage. Premium: The amount paid, often on a monthly basis, for health insurance. The cost of the premium may be shared between employers or government purchasers and individuals. Premium Subsidies: A fixed amount of money, or a designated percentage of the premium cost, that is provided to help people purchase health coverage. Premium subsidies are usually provided on a sliding scale based on an individual s or family s income. Preventive Care: Healthcare that emphasizes the early detection and treatment of diseases. The focus on prevention is intended to keep people healthier for longer, thus reducing healthcare costs over the long term. Reinsurance: Reinsurance is insurance for insurance companies and employers that selfinsure their employees medical costs. Through government-funded reinsurance programs, federal or state governments pay for a portion of the high costs experienced by insurers. By limiting insurers exposure to very high health costs, reinsurance programs enable insurers to lower the premiums they charge to employers and individuals. This type of program is a form of subsidy to the insurer that lowers the premium cost for all purchasers. The Healthy New York program and the Healthcare Group of Arizona are examples of state reinsurance programs. Glossary Source Glossary of Key Terms in Health Reform, (#7909) The Henry J. Kaiser Family, September 2010 This information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible analysis and information on health issues. 15 Health Reform Survival Guide

21 Resources Pre-Existing Condition Insurance Plan: pcip.gov The Commonwealth Fund: commonwealthfund.org Kaiser Family Foundation: kff.org Medicare: Medicare.gov Department of Labor: DOL.gov Health Reform: HealthCare.gov Department of Health and Human Services: hhs.gov Internal Revenue Service: irs.gov Early Retiree Reinsurance Program: errp.gov CO-OP: Health Advocate: HealthAdvocate.com Healthcare Survival Guide: HealthcareSurvivalGuide.com Disclaimer The materials in this booklet have been prepared by Health Advocate, Inc. for general information purposes only. These materials do not, and are not intended to, constitute legal or other professional advice and you should not act, or refrain from acting, solely on the basis of information included here without first seeking appropriate legal counsel or other professional advice. Health Reform Survival Guide 16

22 About Health Advocate Health Advocate, Inc. is the nation s leading independent healthcare advocacy and assistance company, serving 40+ million Americans through more than 10,000 client relationships, including many of the nation s largest companies, by helping members personally navigate healthcare and insurance-related issues, saving time and money. Our leading-edge solutions include EmpoweredHealth, a fully integrated program featuring a single 800#, that seamlessly combines health advocacy, wellness coaching, EAP+Work/Life and chronic care solutions. We also leverage the power of pricing transparency, personalized health communications and more to help members make more informed decisions and get more value out of the healthcare system. All supported by a powerful data analytics engine delivering improved health and financial results. Founded in 2001 and headquartered in suburban Philadelphia, Health Advocate has been recognized, for the sixth consecutive year, as one of America s fastest growing private companies by Inc. 500, named one of the fastest growing companies in North America on Deloitte s 2012 Technology Fast 500, winner of the 2012 Inc. Hire Power Award, the 2011 Workforce Management Magazine Worldwide Optimas Award for Service and the Philadelphia Business Journal s Healthiest Employees Award. Health Advocate regularly publishes White Papers and other publications on a range of timely health and wellness-related topics. Martin Rosen and Abbie Leibowitz, M.D., two of the cofounders, are the authors of the award-winning book, The Healthcare Survival Guide. 17 Health Reform Survival Guide

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