Blue Cross and Blue Shield of Nebraska MA Assure (HMO-POS) Medicare Advantage Plan H3170-004 • 2027 • Grant County, NE
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- $0.00
- Maximum Out-of-Pocket
- $5900.00In-network
- Part B Giveback
- Not offered
- Prescription Coverage
- Enhanced, $400.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- Grant County, NE
- Local Enrollment
- 0 beneficiaries in Grant County
Blue Cross and Blue Shield of Nebraska MA Assure (HMO-POS) Introduction
This Medicare Advantage HMO-POS plan, Blue Cross and Blue Shield of Nebraska MA Assure, is offered by Blue Cross and Blue Shield of Nebraska and uses a Health Maintenance Organization with a Point of Service (HMO-POS) provider network. It comes with prescription drug coverage. For the 2027 plan year, the monthly premium is $0.00, the medical deductible is $0.00, and the in-network maximum out-of-pocket is $5900.00. The plan is identified by CMS Plan ID H3170-004. The 2027 Part D prescription drug deductible is $400.00.
Enrollment in this plan requires residence in Grant County, Nebraska. CMS enrollment data reports 0 plan members in Grant County. New members can call the plan directly at (844)899-6060 (TTY 711) for assistance.
Compare Similar Plans in Grant County
No other HMO-POS plans are available in Grant County, Nebraska using the same plan-type comparison criteria.
Plan Benefits
Cost-sharing for Blue Cross and Blue Shield of Nebraska MA Assure includes out-of-pocket expenses for covered healthcare services. The following tables provide a summary of typical in-network out-of-pocket costs for plan H3170-004.
You can also compare 2027 costs and coverage with last year, side-by-side: Plan H3170-004-0 Cost Compare.
Office Visits
- Primary care
- In-network: $0 copay
- Specialist
- In-network: $45 copay
Preventive and Wellness Services
- Annual wellness exam
- In-network: $0 copay
- Telehealth benefit
- In-network: $0-$60 copay
- Routine chiropractic
- Not covered
- Fitness benefits
- Coming soon
- Health education
- Not covered
- Counseling services
- Not covered
- Over-the-counter drug benefits
- In-network: $0 copay
- Health transportation (non-emergency)
- Coming soon
Diagnostic, Lab, and Imaging Services
- Diagnostic radiology services
- In-network: $0-$225 copay
- Lab services
- In-network: $0 copay
- Outpatient x-rays
- In-network: $40 copay
- Diagnostic tests and procedures
- In-network: $0-$525 copay
Emergency and Urgent Care Services
- Emergency room care
- $130 copay
- Worldwide emergency care
- Coming soon
- Urgent care
- $40 copay
- Inpatient hospital care
- In-network:
Tier 1
$525 per day for days 1-5
$0 per day for days 6-90
$0 per stay - Skilled Nursing Facility
- In-network:
Tier 1
$0 per day for days 1-10
$10 per day for days 11-20
$218 per day for days 21-100 - Ground ambulance
- In-network: $325 copay
Mental Health Services
- Outpatient individual therapy
- In-network: $45 copay
- Outpatient group therapy
- In-network: $45 copay
- Inpatient psychiatric hospital care
- In-network:
Tier 1
$525 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Rehabilitation Services
- Physical therapy and speech and language therapy
- In-network: $45 copay
- Occupational therapy
- In-network: $45 copay
Medical Equipment and Supplies
- Diabetes supplies
- In-network: 0%-20% coinsurance
- Durable medical equipment
- In-network: 20% coinsurance
- Prosthetics
- In-network: 20% coinsurance
Medicare Part B Drugs
- Chemotherapy
- In-network: 0%-20% coinsurance
- Other Part B drugs (Medicare-covered)
- In-network: 0%-20% coinsurance
Dental Services
- Oral exam
- In-network: $0 copay
- Dental x-rays
- In-network: $0 copay
- Cleaning
- In-network: $0 copay
- Periodontics
- Not covered
- Endodontics
- Not covered
- Restorative services
- Not covered
- Implant services
- Not covered
- Orthodontics
- Not covered
- Oral/Maxillofacial surgery
- Not covered
Vision Services
- Routine eye exam
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Contact lenses
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Eyeglass frames only
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Eyeglass lenses only
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Eyeglasses (frames & lenses)
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Upgrades
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance
Hearing Services
- Hearing exam
- In-network: $0 copay
- Fitting/evaluation
- In-network: $0 copay
- Prescription hearing aids
- In-network: $495-$1695 copay
- OTC hearing aids
- Not covered
Additional and Special Needs Services
- Adult day health services
- Not covered
- Home-based palliative care
- Not covered
- Personal emergency response system
- Coming soon
- Weight management programs
- Not covered
- Wigs for chemotherapy-related hair loss
- Coming soon
- Alternative therapies
- Not covered
- Massage therapy
- Not covered
- Home/bathroom safety devices
- Not covered
Certain preventive services are covered 100% by Blue Cross and Blue Shield of Nebraska MA Assure as a Part B benefit.
Prescription Drug Coverage
Blue Cross and Blue Shield of Nebraska MA Assure includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $0.00 |
| Supplemental Part D Premium: | $$0.00 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $24.60 |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $400.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Blue Cross and Blue Shield of Nebraska starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, Blue Cross and Blue Shield of Nebraska MA Assure may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | Coming soon |
| Generic | $5.00 copay | Coming soon |
| Preferred Brand | 15% coinsurance | Coming soon |
| Non-Preferred Drug | 27% coinsurance | Coming soon |
| Specialty Tier | 25% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H3170)
CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | Not enough data available |
| Member Experience with Health Plan | Not enough data available |
| Complaints and Changes in Plans Performance | Not enough data available |
| Health Plan Customer Service | Not enough data available |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | Not enough data available |
| Member Experience with the Drug Plan | Not enough data available |
| Drug Safety and Accuracy of Drug Pricing |
Contact Information for Blue Cross and Blue Shield of Nebraska
- Website
- Blue Cross and Blue Shield of Nebraska Plan Page
- Providers
- Blue Cross and Blue Shield of Nebraska Providers Page
- Formulary
- Blue Cross and Blue Shield of Nebraska Formulary Page
- Pharmacy
- Blue Cross and Blue Shield of Nebraska Pharmacy Page
- New Member Health Plan Help
- (844)899-6060
- New Member Health Plan TTY
- 711
- New Member Part D Help
- (844)899-6060
- New Member Part D TTY Users
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Blue Cross and Blue Shield of Nebraska (official source) | https://Medicare.NebraskaBlue. | October 4, 2026 |
| CMS.gov | Medicare Advantage Plan Fact Sheet | 25 May, 2025 |
| AARP.org | The Big Choice: Original Medicare vs. Medicare Advantage | 25 May, 2025 |
| Medicare.gov | Your coverage options | 25 May, 2025 |
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