Fifteen Dollars a Test, Up to $750: New York's Plan for the Addiction With No Medication

A patient with a stimulant use disorder walks into a clinic, provides a urine sample, and leaves with about fifteen dollars loaded onto a gift card. A few days later she comes back, tests negative again, and the value goes up. If she stays abstinent long enough, the clinic will eventually have handed her as much as $750.

New York State intends to start paying people for stimulant-negative drug tests next month, at eight outpatient clinics that do not dispense methadone or buprenorphine. OASAS Commissioner Chinazo Cunningham described the design on Oct. 27 at the annual symposium of the Coalition of Medication-Assisted Treatment Providers and Advocates, a livestreamed event where state officials also walked through the Medicaid changes arriving in January.

The pilot runs 18 months. For the first twelve weeks, patients with a primary stimulant use disorder attend twice a week, several days apart, and give a urine sample on the spot each time. A stimulant-negative result earns a gift card worth roughly $15. The amount escalates with consecutive negative tests toward the federal ceiling of $750. Miss an appointment or test positive, and the incentive restarts at zero. After twelve weeks, visits drop to once a week for another twelve.

The pilot, in its actual mechanics

The twice-weekly schedule is the part that looks arbitrary and isn't. Cocaine and methamphetamine metabolites clear the body within two to four days. A clinic that tests weekly can be beaten by anyone willing to time a binge around the appointment. Testing twice a week at irregular intervals closes that window, which is why the federal advisory that governs these programs treats frequent, unpredictable testing as a fidelity requirement rather than an administrative preference.

Cunningham was direct about the evidence base and about why the model is rare in practice. "Contingency management has been studied for decades around drug use, and it's definitely known to be effective," she said, adding that "implementing it in the real world is very difficult." She would know. Cunningham led a seven-year, NIH-funded study of the intervention and said that even with a large annual budget she struggled to make it work operationally.

New York is not inventing the method. It is trying to run it at state scale for the first time, in a health system where the payment side has historically been the obstacle.

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There is no pill for this

Opioid use disorder has three approved medications and a decade of federal policy pushing them into every jail and emergency department. Stimulant use disorder has none. The Food and Drug Administration has not approved a single medication for cocaine or methamphetamine dependence, and SAMHSA's January 2025 advisory is blunt about the consequence: in the absence of approved drugs, contingency management "is considered a primary and potentially life-saving intervention" for the more than four million Americans who meet diagnostic criteria.

Cunningham noted that slightly more Americans have a stimulant use disorder than an opioid use disorder, a population largely invisible in a state whose addiction spending organized itself around opioids and the settlement money that followed. She also described the racial shape of the problem in terms that cut against the usual framing of progress: people of color in New York are dying at the highest rates, even though Black New Yorkers recorded the largest reduction in overdose deaths between 2023 and 2025.

The clinical case for paying patients is stronger than it sounds. The advisory cites a median of 24 weeks of continued benefit after incentives stop, measured against cognitive behavioral therapy, 12-step facilitation, and intensive outpatient treatment. It also notes that the approach can be pointed at medication adherence rather than abstinence when that is the more useful target.

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The $750 number is new, and it is not the whole cost

For years the practical ceiling on these programs was $75 per patient per year, a figure that traced back to federal grant notices and a widespread belief that health care fraud rules capped incentives there. SAMHSA changed that in January 2025, raising the allowed value to $750 per patient per year for grantees whose awards authorize the activity. The agency said the old number could not change behavior.

Two constraints survived the increase. Cash payments remain prohibited, so the incentives have to be gift cards, vouchers, or items that support recovery. And the escalating-then-reset schedule is mandatory, because a flat payment for a negative test is not the intervention that was studied.

Item	Before January 2025	Now
Federal grant ceiling	$75 per patient per year	$750 per patient per year
Form of incentive	Items or vouchers	Items, vouchers or gift cards, no cash
Schedule	Escalating	Escalating, resets on a miss or positive test
OIG safe harbor for 2025	$605 per patient per year	$605 per patient per year

That last row is the awkward one, and SAMHSA put it in its own footnote. The $750 maximum sits above the $605 safe harbor figure that the HHS Office of Inspector General set for 2025. The advisory's answer is that falling outside a safe harbor is not the same as violating the anti-kickback statute, and it points to preamble language in the underlying regulation saying exactly that. Providers reading the document carefully will notice they are being asked to operate in a space that is permitted but not protected.

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The waiver that pays for it expires in March

Here the pilot runs into a calendar problem. Medicaid cannot simply buy gift cards. New York pays for contingency management through its Medicaid Redesign Team Section 1115 demonstration waiver, which is authorized through March 31, 2027. The pilot begins in November 2026 and runs 18 months, which puts its final seven months past that expiration unless CMS renews.

New York asked for a five-year extension on Sept. 30, in a letter signed by Governor Kathy Hochul, following two public hearings and more than 190 comments. The application is specific about what continues and what stops. It wants to keep IMD authority for residential addiction treatment, arguing that continued authority is what preserves statewide residential capacity. It wants to discontinue Demonstration Services 9, the package covering residential addiction services, crisis intervention, and licensed behavioral health practitioner services, on the grounds that those services have moved into the standard managed care benefit and no transition plan is needed.

What the application does not do is name the thing Cunningham announced four weeks later. A full-text search of the submitted document returns no reference to contingency management, no reference to vouchers, and no mention of the $750 threshold. That is not proof the state forgot about it, and payment authority can be pursued through a separate amendment. But it does mean that the single largest expansion of stimulant treatment in New York's history is, as of this week, a pilot with no stated line in the waiver request that would fund it after March.

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What the state bought with the rest of the OUD money

The symposium was not only about stimulants. Cunningham ran through the corrections numbers, which are the most favorable figures the state has to present. New York now has 140 outpatient methadone programs and offers all forms of medication for opioid use disorder in 41 prisons and 58 jails. Nationally, fewer than half of jails offer the medications at all.

The growth rates are dramatic enough to require care in reading.

Setting	Period	Change
State prisons, people receiving MOUD	2022 to 2025	7-fold increase
State prisons, first-time MOUD starts	2022 to 2025	360-fold increase
Jails, people enrolled in MOUD	2022 to 2024	tripled
Jails, share on buprenorphine, 2024	—	83 percent

The 360-fold number

A 360-fold increase sounds like a data error and is mostly an artifact of where the state began. A handful of first-time starts in 2022 becomes a large multiple on a small base. The more meaningful figure is the seven-fold rise in the total number of incarcerated people receiving medication, and even that understates the operational change, since it reflects a decision to continue treatment that people were already on rather than to start new patients from nothing.

Cunningham's explanation for why this was hard is worth keeping. "When you've seen one jail, you've seen one jail," she said, describing 58 county sheriffs with 58 different views of the same medication. She also gave the number that justifies the effort: incarcerated people die of overdose at more than 100 times the rate of the general population, and provision of medication in custody has been shown to reduce overdose risk after release.

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Take-home doses moved the clinic floor

The other structural change at the symposium was one that never appears in a press release. Federal rules made permanent in 2024 allow far more methadone to go home, and the state's treatment programs have been rearranging themselves around the consequences.

At Strong Recovery in Rochester, medical director Myra Mathis described adding a role that did not exist a few years ago: an engagement specialist whose job is to find patients who have stopped showing up for individual or group therapy for three months and offer them a dispensing-only track. That track comes with conditions, including naloxone and other harm reduction supplies for patients who are unstable, safety planning, and screening for suicidal thinking. The specialist meets each patient at least quarterly, which is also what keeps the billing compliant.

Mathis called the end of the therapy requirement a positive change and then named its cost: patients who take their doses home sometimes stop coming to counseling entirely, and the program has to go find them.

Brett Palmer, a physician assistant in outpatient practice, put the other side plainly. "The safety of methadone, it is a medication that we have to be very careful with," he said, noting real diversion risk that patients sometimes admit to, and describing take-home decisions as a frequent, judgment-heavy conversation rather than a formula.

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The coverage underneath all of it

Every intervention discussed at the symposium depends on people remaining insured, and that assumption is about to be tested. Trisha Schell-Guy, who directs program development for the state's Office of Health Insurance Programs, said up to a million New Yorkers on Medicaid will be subject to work requirements under the federal reconciliation law, beginning with new applicants on Jan. 1, 2027, followed by renewal dates in March.

There are three ways to comply: household income of at least $580 a month, 80 hours of an approved activity in a month, or some combination of the two. Exemptions cover certain age groups, people with qualifying conditions, American Indian and Alaska Native members, and foster youth, and there are six-month hardship exemptions for high-unemployment counties and disaster areas. The state is seeking one of those for the Bronx. For the first year New York will rely on attestation, a short questionnaire, and will stop accepting attestation in 2028.

Meanwhile, the extension application that would fund much of this sits with CMS, and the stimulant pilot sits beside it with no explicit line item. What happens in eight clinics between November and next spring is therefore a test of two things at once: whether paying people for negative tests works at state scale, and whether the state can keep the payment authority long enough to find out.

For anyone who needs treatment now, OASAS runs the HOPEline at 1-877-8-HOPENY (1-877-846-7369), staffed around the clock, and SAMHSA's National Helpline at 1-800-662-4357 operates 24 hours a day in English and Spanish. Both refer to Medicaid-accepting programs regardless of ability to pay.