Each year billions of federal dollars are up for grabs as insurers compete to score a star rating high enough to earn a lucrative financial bonus in the Medicare Advantage program. Last year, more than $6 billion in bonuses were awarded to various types of privately run MA plans.

Obtaining a bonus is especially important as plans use that funding to sell supplemental benefits, or extra perks that can be enticing to shoppers and can attract more people to their rolls.

However, the bonus program is costly and has been pegged as an area ripe for trimming, according to a 2018 Congressional Budget Office report that suggested changes could help reduce the federal deficit.

Still, insurers take the stars program seriously and devise strategies to snag higher scores. It stokes competition among plans and promotes robust benefit offerings as issuers are forced to use some of those dollars on supplemental benefits such as dental or vision.

"There is not a silver bullet," for a stars strategy, Dustin Grzeskowiak, an actuary for consulting firm Milliman, told Healthcare Dive.

However, highly rated plans often have a few characteristics in common, he said.

Top-rated plans tend to be part of a company with an overall culture of supporting and championing the stars program. Sophisticated data-driven strategies are also key, along with member outreach.

At Kaiser Permanente, there is a disciplined structure around star ratings, Agnes Strandberg, senior vice president of Kaiser's Medicare program, told Healthcare Dive.

Her team is focused on reviewing data, key metrics and predictive analytics to understand emerging trends among members. The focus on analytics also helps identify best practices throughout the organization's regions, which is a hallmark of integrated health systems, Strandberg said.

A core pillar for California-based Kaiser is ensuring a consistent member experience across all those regions, which requires a lot of training, she said.

Being an integrated health system provides an important foundation for these goals, Strandberg said.

For example, when a Kaiser member walks into a clinic for a visit, the receptionist may remind the patient they're due for a mammogram and attempt to go ahead and schedule one. The pharmacist also is there not just to fill prescriptions but to play a role in advancing a member's health. Staying current on screenings such as mammograms are an important metric that play into the star ratings.

The health plan and its clinicians are essentially playing for the same team and not at odds with one another, which can be the case for other non-affiliated payers and providers.

All told, Kaiser garnered five-star ratings for seven of its health plans in the most recent ranking, the most of any payer. Together the seven plans cover more than 1.5 million people.

Overall, only 23 plans out of 401 received the top grade, according to CMS.

Another top performer was Bloomfield, Conneticut-based Cigna.

Cigna's Florida plan was one of 23 plans to earn a perfect score of five stars. The plan, Healthspring, covers more than 48,000 seniors throughout the sunshine state.

Cigna officials say it's not about "teaching to the test" or varying strategies each year for the best results. Instead, the company has doubled down on member satisfaction, David Meyer, vice president of Cigna's stars program, told Healthcare Dive. 

"Happy customers give you better scores," Meyer said. "And then, I think, the rates come."

For example, in one of the many listening sessions the company holds with its customers, Cigna realized that it wasn't more apps or smartphone support that members wanted but more ways to access their "passport to health" — a booklet for collecting important health information and appointment and screening dates. They wanted a hard copy version sent to their house. That was somewhat of a surprise, Meyer said.

Cigna's stars team often rolls out pilots to see what keeps customers happy. Right now, in some markets, doctors have agreed to alert patients when they're running behind and by how many minutes by noting it on a whiteboard in the waiting room.

Keeping customers happy is through lots of small things, Meyer said. "We absolutely sweat the small stuff," he said.

But for all the focus on stars, it's not a key factor for patients when picking their plans, Gretchen Jacobson of the Kaiser Family Foundation told Healthcare Dive. Patients are concerned about picking a plan that includes their doctor and other benefits.

"Seniors were pretty clear that they as whole do not use the star ratings when selecting a plan," Jacobson said of KFF's results from focus groups.

While more members are in highly-rated plans, what's key to pay attention to is the under-performing plans, Jacobson said.

It's important to keep an eye on the habitual low scorers, which are supposed to be kicked off the program after a certain period of time, she said.

In February of this year, CMS sent a memo to insurers warning them that it would terminate plans for low scores. The memo said it was resuming its authority to do so after a moratorium that expired Dec. 31.

Next year's will be the first set of ratings to be counted toward qualification for a possible termination. A plan risks that fate if it falls below three stars for three consecutive years, an agency spokesperson said.

This year, five plans were flagged as low performers. Four of those plans had low enrollment, fewer than 5,000 members. But, one plan, Merit Health Insurance sold by Magellan Health Inc., had more than 63,000 enrollees. These plans have garnered 2.5 or fewer stars from at least 2018 through 2020, according to CMS.