How Highmark, Alignment earned top Medicare Advantage star ratings

It's harder than ever for health insurance companies to earn high Medicare Advantage star ratings and the bonuses that come with them. But, as a handful of companies has shown, it's not impossible.

“The rules are what the rules are,” said Bill Rayball, vice president of government quality at Highmark Health, which earned five-out-of-five stars for one Medicare Advantage contract, which comprises multiple plans. “In some cases, you're aiming for perfection and that is difficult. But I think it's being demonstrated that it can be achieved.”

Related: CMS keeps raising the bar for Medicare Advantage star ratings

The Centers for Medicare and Medicaid Services has toughened the standards for insurers to win high quality scores after the agency relaxed the rules during the COVID-19 pandemic, leading to grade inflation and booming spending on bonus payments.

New regulations and tweaks to the formula that calculates star ratings have had the effect CMS intended. For 2025, only seven Medicare Advantage with prescription drug coverage contracts earned five-star ratings, the agency announced last month. That’s drastically down from 38 contracts in 2024, 57 in 2023 and 74 in 2022. The annual enrollment period began Oct. 15 and ends Dec. 7.

Across the board, plans are scoring worse, albeit with exceptions. The average star rating for 2025 is 3.92 compared with 4.07 this year. Medicare Advantage contracts rated four or higher earn 5% quality bonus payments, which they can use to finance extra benefits, reduced cost-sharing and zero-premium plans. Smaller bonus payments have led insurers to make cutbacks to benefits and to exit from unfavorable geographic markets — and provoked consternation among health insurance investors.

“CMS continues to implement enhancements to the MA and Part D Star Ratings program to promote continual quality improvement to help ensure that Medicare enrollees receive high quality care and to incentivize plans to continue to strive for higher quality,” a CMS spokesperson said.

Medicare Advantage market share leaders UnitedHealth Group and Humana, which operate several five-star contracts this year, are not on the exclusive list for 2025.

While the sector continues to grapple with an overall decline in star ratings, Highmark Health, Alignment Health, Network Health and a few others are relishing the "high-performing icon" next to their five-star contracts on the Medicare Plan Finder website and are preparing to market year-round, a privilege only extended to the top plans.

“You'll notice none of them are the huge players. They know their members, they know their region, they know their provider networks, and they know their data,” said Suzanna-Grace Tritt, a senior consulting actuary at Wakely Consulting Group.

Shooting for the stars

There’s no one-size-fits-all solution to stars, executives and experts said. Identifying strengths and weaknesses, fortifying relationships with members and providers, and making high ratings a business objective are a few ways Highmark, Alignment and Network Health have retained five-star contracts over consecutive years, executives said.

“We picked North Carolina three years ago, and said we want this market to be a five-star plan, and we want to know everything in its entirety,” said Dawn Maroney, CEO of Alignment Health Plan and president of markets for Alignment Health.

The company's North Carolina team occasionally works overtime and on weekends, Maroney said. “If the outreach is not happening, because we have a centralized resource, they go above and beyond the call of duty,” she said. “What we're trying to do is: How do you scale that across the organization, but not requiring everybody to work seven days a week?”

Alignment Health Plan employee bonuses are tied to stars, Maroney said. For example, incentives for customer service staff are linked to call timeliness, and employees who handle medication adherence are eligible for extra pay based on how well their interventions work for members, she said.

It's an ongoing process, Maroney said. The chief executive meets with teams in different markets daily to review how they are progressing on metrics. Alignment Health Plan may consider sending mobile health units, allocating more financial resources or approving out-of-network care in certain circumstances to improve performance, she said.

“How do you make sure that, at the end of the day, it's not just stars, but it improves care?” Maroney said.

Network Health, a regional carrier in Wisconsin with $1.2 billion in revenue, leans into its community affiliations to bolster performance, said Coreen Dicus-Johnson, president and CEO of the insurer, which is owned by the Milwaukee- and Neenah, Wisconsin-based health system Froedtert ThedaCare Health.

Dicus-Johnson emphasized customer service employee and member retention as key to earning high star ratings. The Network Health call center has about 90% worker retention and has about 95% member retention, she said.

“What that means is we can build a relationship with members,” Dicus-Johnson said. “They know that they're going to get the right advice, they're going to get the right information. They're going to act upon that and that translates into performance in terms of our stars.”

Network Health also analyzes state-specific data to inform its priorities, Dicus-Johnson said. For example, Wisconsin has the highest rate of falls nationwide, so the company put more emphasis on reducing fall risk, she said.

Highmark takes a broad approach that focuses on multiple star ratings metrics, Rayball said.

“You can't focus on just a subset and expect to be successful," Rayball said. “It really requires you to be firing on all cylinders for the entirety of the measure set, and that requires the entire organization to pull its share of the weight.”

For example, the company redoubled efforts to communicate with providers about changes to benefits, including when medications are moved to different formulary tiers or lower-cost options are added, he said.

Awareness of generic pharmaceuticals and other alternatives can boost metrics on medication adherence, drug benefits and access to prescription medicines. Highmark’s five-star contract overlaps with the geographic footprint of its affiliated health system, Pittsburgh-based Allegheny Health Network, which is another advantage, Rayball said.

A glimmer of what's to come

Consultants and actuaries recommend health insurers emphasize the most heavily weighted measures, model scenarios of how a plan would score if "cut points" — the threshold between one score and the next — moved by various degrees, determine where other insurers did well and identify where CMS has indicated interest in raising cut points.

Medicare Advantage insurers need to keep striving for top scores to not fall behind, said Matthew Smith, an actuary at the consulting firm Milliman.

“You never really cross the finish line in stars,” Rayball said. “You're always driving for continuous improvement. We never get there. You're always looking for that next rung of the ladder.”