Blue Cross and Blue Shield of Nebraska MA Assure (HMO-POS) Medicare Advantage Plan H3170-004 • 2027
- 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
- See List
- Total Enrollment
- 0 beneficiaries
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.
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.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay | Coming soon |
| Specialist | In-network: $45 copay | Coming soon |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | In-network: $0 copay | Coming soon |
| Telehealth benefit | In-network: $0-$60 copay | Coming soon |
| Routine chiropractic | Not covered | Coming soon |
| Fitness benefits | Coming soon | Coming soon |
| Health education | Not covered | Coming soon |
| Counseling services | Not covered | Coming soon |
| Over-the-counter drug benefits | In-network: $0 copay | Coming soon |
| Health transportation (non-emergency) | Coming soon | Coming soon |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: $0-$225 copay | Coming soon |
| Lab services | In-network: $0 copay | Coming soon |
| Outpatient x-rays | In-network: $40 copay | Coming soon |
| Diagnostic tests and procedures | In-network: $0-$525 copay | Coming soon |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $130 copay | Coming soon |
| Worldwide emergency care | Coming soon | Coming soon |
| Urgent care | $40 copay | Coming soon |
| Inpatient hospital care | In-network: Tier 1 $525 per day for days 1-5 $0 per day for days 6-90 $0 per stay |
Coming soon |
| 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 |
Coming soon |
| Ground ambulance | In-network: $325 copay | Coming soon |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: $45 copay | Coming soon |
| Outpatient group therapy | In-network: $45 copay | Coming soon |
| 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 |
Coming soon |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: $45 copay | Coming soon |
| Occupational therapy | In-network: $45 copay | Coming soon |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: 0%-20% coinsurance | Coming soon |
| Durable medical equipment | In-network: 20% coinsurance | Coming soon |
| Prosthetics | In-network: 20% coinsurance | Coming soon |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: 0%-20% coinsurance | Coming soon |
| Other Part B drugs (Medicare-covered) | In-network: 0%-20% coinsurance | Coming soon |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0 copay | Coming soon |
| Dental x-rays | In-network: $0 copay | Coming soon |
| Cleaning | In-network: $0 copay | Coming soon |
| Periodontics | Not covered | Coming soon |
| Endodontics | Not covered | Coming soon |
| Restorative services | Not covered | Coming soon |
| Implant services | Not covered | Coming soon |
| Orthodontics | Not covered | Coming soon |
| Oral/Maxillofacial surgery | Not covered | Coming soon |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Contact lenses | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Eyeglass frames only | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Eyeglass lenses only | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Eyeglasses (frames & lenses) | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
| Upgrades | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Coming soon |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay | Coming soon |
| Fitting/evaluation | In-network: $0 copay | Coming soon |
| Prescription hearing aids | In-network: $495-$1695 copay | Coming soon |
| OTC hearing aids | Not covered | Coming soon |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Coming soon |
| Home-based palliative care | Not covered | Coming soon |
| Personal emergency response system | Coming soon | Coming soon |
| Weight management programs | Not covered | Coming soon |
| Wigs for chemotherapy-related hair loss | Coming soon | Coming soon |
| Alternative therapies | Not covered | Coming soon |
| Massage therapy | Not covered | Coming soon |
| Home/bathroom safety devices | Not covered | Coming soon |
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.
Plan Availability
Blue Cross and Blue Shield of Nebraska MA Assure (H3170-004-0) is available in the following locations:
Nebraska Counties Served
- Adams
- Antelope
- Arthur
- Blaine
- Buffalo
- Cass
- Cedar
- Chase
- Clay
- Colfax
- Custer
- Deuel
- Dodge
- Douglas
- Dundy
- Fillmore
- Franklin
- Frontier
- Furnas
- Gage
- Garden
- Garfield
- Grant
- Greeley
- Hall
- Hamilton
- Harlan
- Hayes
- Hitchcock
- Hooker
- Howard
- Jefferson
- Kearney
- Keith
- Knox
- Lancaster
- Lincoln
- Logan
- Loup
- Madison
- Mcpherson
- Nance
- Nemaha
- Nuckolls
- Otoe
- Perkins
- Platte
- Polk
- Red Willow
- Sarpy
- Saunders
- Seward
- Sherman
- Thomas
- Thurston
- Valley
- Washington
- Wayne
- Webster
- Wheeler
- York
Frequently Asked Questions
Here are some of the most frequently asked questions about this plan (click to open).
Frequently Asked Questions About Blue Cross and Blue Shield of Nebraska MA Assure (HMO-POS)
What is the monthly premium for Blue Cross and Blue Shield of Nebraska MA Assure (HMO-POS)?
The 2027 monthly premium is $0.00. The Medicare Part B premium is paid separately.
What is the in-network MOOP for plan H3170-004?
For 2027, the in-network maximum out-of-pocket is $5900.00. The plan pays 100% of covered in-network services beyond this amount.
What is the CMS star rating for this plan?
CMS rates this plan at ★0.0 out of 5 stars for 2027.
What is the total enrollment for plan H3170-004?
Total enrollment is 0 beneficiaries based on the latest CMS data.
What is the Part D deductible for plan H3170-004?
The plan’s Part D deductible is $400.00, applied to covered prescription drug costs.
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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