# What Does Dual Eligible Mean? Medicare and Medicaid Riders and Who Pays for Their Rides

Canonical URL: https://nemtguide.com/glossary/dual-eligible/ · Updated 2026-09-29

Dual eligible means a person is enrolled in both Medicare and Medicaid. Full-benefit dual eligible members get full Medicaid benefits, so Medicaid covers their van and sedan rides to covered care, while Original Medicare pays only for qualifying ambulance trips. Partial-benefit members get help only with Medicare costs and usually have no Medicaid ride benefit, though a Medicare Advantage plan may offer rides.

- Dual eligible riders have Medicare and Medicaid. In fiscal year 2025, 72 percent had full Medicaid benefits and 28 percent had only help with Medicare costs.
- For a full-benefit rider, Medicaid covers van and sedan rides to covered care, even when Medicare pays for the visit itself.
- QMB only, SLMB only, QI, and QDWI riders generally have no Medicaid ride benefit.
- A dual special needs plan may offer its own rides, and a state can require those trips to be used before Medicaid pays.
- Starting in 2027, a company with both a D-SNP and a Medicaid plan in the same area must limit new D-SNP enrollment to its Medicaid members.

Many of your riders carry two cards, one for Medicare and one for Medicaid. Which card pays for the ride depends on what kind of Medicaid the rider has and whether a Medicare plan adds rides of its own.

## What dual eligible means

A dual eligible person is enrolled in Medicare and in Medicaid at the same time. They may qualify for Medicare by age, disability, or end-stage renal disease, and for Medicaid by income and other rules. CMS's Medicare-Medicaid Coordination Office counted nearly 12.5 million dual eligible people on average during fiscal year 2025, and nearly 14 million enrolled at some point in 2025 (report to Congress, July 2026). Of the 12.5 million, 72 percent had full Medicaid benefits and 28 percent had partial benefits, and 32 percent were under 65.

The split is the part that matters for rides:

- **Full-benefit dual eligible** members get the full Medicaid benefit package, rides included. Federal rule 42 CFR 423.772 defines them as people with Medicare drug coverage whom the state finds eligible for full Medicaid benefits.
- **Partial-benefit dual eligible** members get Medicaid help only with Medicare premiums and, for QMBs, Medicare cost sharing, through the Medicare Savings Programs.

States report each person's category to CMS as a code. CMS's Dual Eligibility Categories (revised February 11, 2026) sets out each one, with the 2026 federal floor for monthly income for one person:

| Category (code) | What Medicaid pays | Monthly income limit, one person, 2026 | Medicaid rides |
|---|---|---|---|
| QMB only (01) | Part A and Part B premiums and Medicare cost sharing | $1,350 | Generally no |
| QMB Plus (02) | The same, plus full Medicaid | $1,350 | Yes |
| SLMB only (03) | Part B premium | $1,616 | Generally no |
| SLMB Plus (04) | Part B premium, plus full Medicaid | $1,616 | Yes |
| QDWI (05) | Part A premium | $5,405 | Generally no |
| QI (06) | Part B premium, as state funding allows | $1,816 | Generally no |
| Other full benefit dual eligible (08) | Full Medicaid | Set by the state | Yes |

States can raise every limit except QDWI's, and federal limits are higher in Alaska and Hawaii, so a rider over them may still qualify. Indiana's transportation module (August 19, 2025) lists QMB only, SLMB only, QI, and QDWI among its benefit plans with no NEMT.

## Which program pays for a dual eligible rider's trip

Medicare pays first for services both programs cover. For rides, that rarely matters, because Original Medicare's only ride benefit is ambulance service when the patient's condition rules out other transportation ([42 U.S.C. 1395x(s)(7)](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x&num=0&edition=prelim)). See [does Medicare cover non-emergency transportation](https://nemtguide.com/guides/does-medicare-cover-nemt/).

CMS's Medicaid Transportation Coverage Guide (SMD 23-006, September 28, 2023) fills the gap. When a full-benefit dual eligible member gets a Medicaid-coverable service that Medicare pays for first, such as a doctor visit, the state must ensure the ride. Rides to services only Medicare covers are optional. A state may choose to cover trips to the pharmacy for Part D drugs, for example, if doing so is cost effective.

| Rider | Van or sedan ride | Ambulance-level trip |
|---|---|---|
| Full-benefit dual eligible, Original Medicare | Medicaid, through the state, its broker, or a health plan | Medicare first, then Medicaid for the balance |
| Full-benefit dual eligible, in a Medicare Advantage or D-SNP plan with rides | The plan's rides may have to be used first, then Medicaid | The plan first |
| Partial-benefit dual eligible | A Medicare plan's rides, or another payer such as the rider or a facility | Medicare or the Medicare plan |

States handle the billing differently. In Indiana, trips for dual eligible Traditional Medicaid members that go through the broker are billed to Verida with a Trip Leg ID, not to Medicare. Trips exempt from the broker are billed to Medicare first, then to the state with the Medicare explanation of benefits if Medicare denies the claim or leaves a balance. In New York, dual eligible members in long-term care plans need prior authorization from Medical Answering Services for rides, except basic and advanced life support ambulance (state FAQs, revised November 2024).

You do not need Medicare enrollment. CMS's January 14, 2025 FAQs say Medicare is not a liable third party for a service from a provider not enrolled in Medicare, so the state pays first, and may use an override code in place of a Medicare denial. The state may ask you to keep yearly documentation that Medicare does not cover your service. See [third party liability](https://nemtguide.com/glossary/third-party-liability/).

Whoever pays, the rider does not. Under [42 CFR 447.15](https://www.ecfr.gov/current/title-42/section-447.15), Medicaid providers must accept Medicaid's payment, plus any copay the state allows, as payment in full.

## How dual special needs plans add rides

A dual eligible special needs plan, or D-SNP, is a Medicare Advantage plan only for people with Medicaid. Under 42 CFR 422.2, it coordinates Medicare and Medicaid services, may cover Medicaid services itself, and must have a contract with the state Medicaid agency. That contract, under 42 CFR 422.107, lists the Medicaid benefits the plan covers and how it checks each member's Medicaid eligibility.

D-SNPs come in three integration levels. CMS's Special Needs Plan report for September 2026 counted 6,486,061 people in 1,082 D-SNP plans:

| Type | What it covers | Enrollment, September 2026 |
|---|---|---|
| Coordination-only D-SNP | Medicare benefits, while coordinating the member's separate Medicaid coverage | 3,373,778 |
| Highly integrated D-SNP (HIDE SNP) | Medicare plus some Medicaid benefits, such as long-term care or behavioral health, under a state contract | 2,312,469 |
| Fully integrated D-SNP (FIDE SNP) | Medicare and Medicaid under one company holding both contracts | 799,814 |

Rides can come from either side. Like other Medicare Advantage plans, D-SNPs may offer supplemental benefits beyond Medicare, and CMS's May 27, 2021 FAQs name non-emergency transportation as one that can overlap with Medicaid. The same FAQs say Medicare pays first for the overlap: a state could require members to use up the D-SNP's trips before Medicaid transportation, and a state's capitated ride vendor must coordinate so trips are not paid twice. For more on these plans, see dual special needs plan and [Medicare Advantage transportation](https://nemtguide.com/guides/medicare-advantage-transportation/).

More dual eligible members are moving into plans where one company covers both programs. MMCO counted about 25 percent of full-benefit dual eligible people in aligned care in 2025, and Medicare-Medicaid Plans in eight states were moved into integrated D-SNPs effective January 1, 2026. Starting in 2027, under [42 CFR 422.514(h)](https://www.ecfr.gov/current/title-42/section-422.514), when a company, or its parent or sister company, offers a D-SNP and holds a Medicaid managed care contract for full-benefit dual eligible members in the same area, it may offer only one D-SNP for them, with limited exceptions, and must limit new enrollment to members of its Medicaid plan. If your state carves rides into its Medicaid plans, ask each plan's ride vendor whether it books both the plan's extra rides and the member's Medicaid rides. See [NEMT carve-out](https://nemtguide.com/glossary/nemt-carve-out/).

## How to handle a dual eligible rider

Dual eligible members ride often. CMS's June 2023 report to Congress found that 14 percent of dual eligible members used NEMT in 2021, averaging 1.7 ride days a month per rider, against 4 percent of all Medicaid members. On July 1, 2024, CMS counted 1,050,580 dual eligible people enrolled in states' separate NEMT programs, including 194,028 in New Jersey and 179,479 in Kentucky.

Before you take the trip:

1. **Ask for every card.** Get the Medicare card, any Medicare Advantage or D-SNP card, and the Medicaid card.
2. **Check Medicaid eligibility for the ride date.** Note whether the rider has full Medicaid or only help with Medicare costs. See [eligibility verification](https://nemtguide.com/glossary/eligibility-verification/).
3. **Ask about plan rides.** If the rider is in a D-SNP or another Medicare Advantage plan, find out whether it covers rides, how many are left, and whether your state requires them to be used first.
4. **Book through the program that pays.** Take Medicaid trips through the state, its broker, or the rider's Medicaid plan. Take plan trips through the plan's ride vendor.
5. **Send ambulance-level trips to an ambulance company.** Medicare or the rider's Medicare plan pays first for those, and a van is not the right vehicle.
6. **Write down what you checked.** Keep the eligibility result and the plan's answer with the trip record. See [NEMT trip documentation](https://nemtguide.com/guides/nemt-trip-documentation/).

## Frequently asked questions

### Does Medicare or Medicaid pay for a dual eligible rider's wheelchair van trip?

Medicaid, if the rider has full Medicaid benefits. Original Medicare covers ambulance trips only, not wheelchair vans or sedans. CMS guidance of September 28, 2023 says that when a full-benefit dual eligible member gets a Medicaid-coverable service that Medicare pays for first, the state must still ensure the ride. A Medicare Advantage plan that offers rides may have to be used first.

### Do QMB only riders get Medicaid rides?

Generally not. QMB only, SLMB only, QI, and QDWI members get Medicaid help with Medicare premiums and, for QMBs, Medicare cost sharing, but not the full Medicaid benefit package. Indiana's transportation module (August 19, 2025) lists all four among benefit plans with no NEMT. Check the rider's dual eligibility category before you book.

### Do I need to enroll in Medicare to drive dual eligible riders?

No. CMS's January 14, 2025 FAQs say there is no federal requirement for Medicaid providers to enroll in Medicare. For a Medicaid-covered service from a provider not enrolled in Medicare, the state pays first, and it may use an override code instead of waiting for a Medicare denial. Your state may ask you to keep yearly records showing Medicare does not cover your service.

### Do dual eligible riders have to use their plan's rides before Medicaid rides?

In some states. CMS's May 27, 2021 FAQs say Medicare pays first when a dual special needs plan and Medicaid cover the same service, and give the example of a state requiring members to use up the plan's trips before Medicaid transportation. Ask your state or broker whether that rule applies where you drive.

### What changes for dual special needs plans in 2027?

Under 42 CFR 422.514(h), starting in 2027, when a company, or its parent or sister company, offers a D-SNP and also holds a Medicaid managed care contract for full-benefit dual eligible members in the same area, it may offer only one D-SNP for them, with limited exceptions, and must limit new enrollment to members of its Medicaid plan. From 2030, those D-SNPs may only enroll or keep members of that Medicaid plan.

## Official resources

- [CMS: Dual Eligibility Categories (codes, income limits, and what Medicaid pays)](https://www.cms.gov/files/document/dual-eligible-categories.pdf-0)
- [CMS: Billing FAQs for dually eligible individuals (January 14, 2025)](https://www.cms.gov/files/document/dualeligiblesproviderenrollmenttplfaqs.pdf)
- [CMS: Coordinating Medicaid benefits and D-SNP supplemental benefits (May 27, 2021)](https://www.cms.gov/files/document/dsnpmedicaremedicaidcoordbenefitsfaqs.pdf)
- [CMS: Special Needs Plan data (monthly D-SNP enrollment by plan)](https://www.cms.gov/data-research/statistics-trends-and-reports/medicare-advantagepart-d-contract-and-enrollment-data/special-needs-plan-snp-data)
- [Medicare.gov: Medicare Plan Finder (compare plan ride benefits by ZIP code)](https://www.medicare.gov/plan-compare/)