EDUCATION

Help Your Patient Stay Protected This Season: Your Guide to Flu, COVID-19, and RSV Vaccines

Cooler temps and respiratory virus season will be here soon. The health and safety of your patients remains a top priority for Medical Associates Health Plans. Our members and your patients will look to you this season to help them navigate information related to vaccine recommendations and safety.

Why Vaccination Matters

• Flu: The flu virus changes each year, so an annual flu shot is the best defense against getting sick—and spreading it to others.
• COVID-19: Immunity from prior infection or vaccination fades over time. Updated COVID-19 vaccines are designed to protect against newer variants and reduce the risk of serious illness. 
• RSV: RSV is common but can be dangerous, especially for adults 50+, infants, and people with weakened immune systems.

Who Should Get Vaccinated?

Flu Vaccine: An annual vaccination is recommended for everyone aged 6 months and older. Ideally administered by the end of October, but receiving it later is still beneficial.

COVID-19 Vaccine: Everyone 6 months and older should stay up to date with the latest recommended vaccine. The FDA-approved use is published on the table below. Recommendations from ACIP for the 2025-2026 COVID vaccines advises that individuals discuss risk vs benefit of receiving these vaccines. We are advising providers send a prescription to a pharmacy if their patient desires a COVID vaccine but does not meet the FDA-approved age + risk factor. By providing a prescription, it signals to the pharmacist that you’ve done shared clinical-decision making regarding the vaccine.

RSV Vaccines/Protection: Adults 75 years and older should receive a single dose of RSV vaccine. Adults 50+ may be eligible based on risk for severe RSV disease. See severe disease risk here.

This is not a yearly vaccine; if your patient has already received it, they do not need to receive another dose.

Timing Tips

• It’s safe to administer flu, COVID-19, and RSV vaccines during the same visit.
• Encourage patients to schedule their vaccinations early to stay protected throughout the peak season.

How Are Vaccines Covered?

All recommended vaccines are covered at no cost to the member when provided by an in-network provider or pharmacy.

Of note, RSV vaccines for Medicare Beneficiaries are a Part D-covered vaccine and would need to be provided at a pharmacy for proper Part D billing. Flu and COVID-19 vaccines can be administered in the office setting and billed to the Medicare Beneficiary’s Part B plan.

If you have any questions about vaccine coverage, please check out the provider guide using your My eLink login or by calling our Member Services team 563-584-4885.

References:

• COVID-19 Vaccines
• RSV Vaccines
• COVID-19 Vaccines (2025-2026 Formula) for Use in the United States Beginning in Fall 2025

QUALITY IMPROVEMENT

Staying Ahead of the Game-Promoting Proactive Health with Your Patients

We are here to support you in delivering high-quality care within your practice. We encourage our health plan members to schedule an Annual Wellness Exam and/or Well Child Exam with a primary care provider, emphasizing the importance of discussing recommended tests and screenings, as well as monitoring blood pressure, blood sugar, and cholesterol levels. Regular visits provide your office with valuable information to address patient needs and deliver the highest quality care. These visits also help close care gaps related to HEDIS Quality Measures and risk adjustment condition reporting.

2025 HEDIS Quality Measures

All Patients

Breast Cancer Screening (BCS)

Women 40-74 years old who have had a Mammogram completed every 2 years.

• Needs to be done between (10/1/23 - 12/31/25).

Exclusions: Mastectomy or Palliative Care/Hospice

Providers note in EMR: When and where Mastectomy or last Mammogram was completed.

Controlling High Blood Pressure (CBP)

Members 18-85 years old whose BP is adequately controlled <140/90 in 2025.

• If BP is 140/90 or greater, always recheck and document.
• Last BP reading of the year is used for HEDIS.

Exclusions: Dialysis, ESRD, Kidney Transplant, Nephrectomy, Pregnant, Palliative Care/Hospice

Providers note in EMR: Elevated BP addressed and rechecked.

Cervical Cancer Screening (CCS)

Women 21-64 years old who have had one of the following:

• Pap performed between (2023-2025).
• High-risk HPV testing/Pap cotesting during (2021-2025).
• HPV testing can not be ordered as reflex.

Exclusions: Hysterectomy no residual cervix or Palliative Care/Hospice

Providers note in EMR: When and where last Pap or HPV testing was completed.

Colorectal Cancer Screening (COL)

Members 45-75 years old who have had one of the following:

• Colonoscopy during (2016-2025).
• Cologuard FIT-DNA test during (2023-2025).
• CT Colonography during (2021-2025).
• Fecal Occult Blood Test during (2025).
• Flex Sig during (2021-2025).

Exclusions: Colorectal Cancer, Total Colectomy or Palliative Care/Hospice

Providers note in EMR: When, where, and type of Colon CA screening was completed.

Diabetic Patients

Blood Pressure Control for Diabetic Patients (BPD)

Members 18-75 years old with DMT1 or DMT2 whose BP is adequately controlled <140/90 in 2025.

• If BP is >140/90, always recheck and document it.
• Last BP reading of the year is used for HEDIS.

Exclusions: Palliative Care/Hospice

Providers note in EMR: Elevated BP addressed and rechecked.

Eye Exam for Diabetic Patients (EEO)

Members 18-75 years old with DMT1 or DMT2 who has had a Retinal or Dilated Eye Exam.

• May be completed in 2024 or 2025, if member does NOT have Retinopathy.
• If member has Retinopathy, eye exam needs to be done in 2025.

Exclusions: Palliative Care/Hospice

Providers note in EMR: When and where last Eye Exam was completed.

Glycemic Status Assessment for Diabetic Patients (GSD)

Members 18-75 years old with DMT1 or DMT2 most recent HbA1c drawn in 2025.

• Need at least 1 HbA1c tested in 2025, preferably under 8%.

Exclusions: Palliative Care/Hospice

Providers note in EMR: When last HbA1c was done. If it was >8% and >3 months ago, recheck it.

Children/Adolescents

Childhood Immunization Status (CIS)

Children who have received the following vaccines by their 2nd birthday in 2025.

• 1 Chickenpox (VZV)
• 4 DTaP
• 1 Hep A and 3 Hep B
• 3 HiB
• 2 Influenza
• 3 IPV
• 1 MMR
• 4 Pneumonia (PCV)
• 2 Rotarix or 3 RotaTeq

Exclusions: Palliative Care/Hospice or Contraindications/Anaphylaxis to Vaccines

Providers note in EMR: What vaccines the member is due for, and if refused, note the reason.

Immunizations for Adolescents (IMA)

Adolescents who have received the following vaccines by their 13th birthday in 2025.

• 2 HPV between 9th-13th birthday with service dates 146 days apart.
• 3 HPV between 9th-13th birthday.
• 1 TDaP between 10th-13th birthday.
• 1 Meningococcal (serogroups A, C, W, Y) between 11th-13th birthday.

Exclusions: Palliative Care/Hospice or Contraindications/Anaphylaxis to Vaccines

Providers note in EMR: What vaccines the member is due for, and if refused, note the reason.

WT Assessment, Counseling for Nutrition & Physical Activity for Children (WCC)

Children 3-17 years old who had an outpatient visit who had evidence of the following in 2025:

BMI % Documentation (WT and HT taken during 2025)

Counseling for Nutrition: Documentation must include 1 of the following:

• Anticipatory Guidance Nutrition
• Nutrition/diet habits discussed
• Educational materials given
• Referral for nutrition education or WIC
• Services for eating disorders
• Weight or obesity counseling

The following does not meet criteria:

• Notation of health education or Anticipatory Guidance without stating Nutrition.
• A PE finding "well-nourished" or documentation related to the member's appetite.
• Treatment for acute/chronic diagnosis

Counseling for Physical Activity: Documentation must include 1 of the following:

• Anticipatory Guidance Physical Activity
• Physical activity discussed/referral
• Educational materials given
• Sports physical/exercise
• Services for eating disorders
• Weight or obesity counseling

The following does not meet criteria:

• Notation of health education or Anticipatory Guidance without stating Physical Activity.
• Treatment for acute/chronic diagnosis

Exclusions: Palliative Care/Hospice or Pregnancy

Providers note in EMR: As stated above what to note and what not to note.

RESOURCES