Coverage Limitations for Use of Urine Drug Testing in a State Medicaid Program

Importance: Urine drug testing (UDT) is commonly used in substance use disorder (SUD) treatment. However, there is little evidence to guide optimal use of UDT and growing concern that some UDT may represent low-value care. Objective: To determine whether a statewide policy limiting Medicaid reimbursement for UDT is associated with testing frequency, expenditures, and clinical outcomes. Design, Setting, and Participants: This serial cross-sectional study was performed among Louisiana Medicaid beneficiaries between July 1, 2017, and February 29, 2020. Data were analyzed from November 1, 2024, to November 30, 2025. For each outcome, best-fit lines for pre-enactment trends were constructed and used to estimate postenactment trends, which were then compared with observed trends. The 3-way interaction of time by intervention period by outcome was analyzed to assess changes for each UDT utilization outcome compared with a matched control procedure (colonoscopy). Concomitant trends in overdose encounters and prescription of medications for opioid use disorder (MOUD) were also assessed. Exposure: Statewide policy limiting Medicaid reimbursement for UDT enacted in July 2019. Colonoscopy rates were used as a temporal comparison procedure. Main Outcomes and Measures: Outcomes included rates of monthly UDT (total, presumptive, and definitive) and expenditures per 1000 beneficiaries for 24 months before and 7 months after policy enactment. Results: The sample included a total of 900 678 unique Medicaid-eligible beneficiaries, 536 841 (59.6%) of whom were female and 606 012 (67.3%) were younger than 40 years. Following policy enactment, the monthly rate of change for total UDT utilization decreased from 0.67 (95% CI, 0.48- 0.85) to -1.03 (95% CI, -1.65 to -0.40) tests per month per 1000 beneficiaries (difference, -1.70 [95% CI, -2.34 to -1.06] tests per month per 1000 beneficiaries); presumptive UDT decreased from 0.42 (95% CI, 0.30-0.53) to -0.63 (95% CI, -0.92 to -0.35) tests per month per 1000 beneficiaries (difference, -1.05 [95% CI, -1.36 to -0.74] tests per month per 1000 beneficiaries); and definitive UDT decreased from 0.25 (95% CI, 0.17-0.34) to -0.39 (95% CI, -0.97 to 0.18) tests per month per 1000 beneficiaries (difference, -0.65 [95% CI, -1.23 to -0.07] tests per month per 1000 beneficiaries). These decreases were all statistically significant compared with colonoscopy (all P < .05). UDT expenditures also significantly decreased, totaling an estimated $14.8 million in savings during the 7-month postenactment period. The policy change was not associated with reduced MOUD receipt or increased overdose encounters. Conclusion and Relevance: In this cross-sectional study, a state policy limiting reimbursement for UDT was associated with significant reductions in UDT utilization and expenditures. Future research and policymaking should investigate ways to optimize UDT for patient health while reducing low-value care.