California Banned Rediagnosis Demands. Texas Medicaid Requires One Every 3 Years.

On September 28 we reported California's AB 951, which since January has barred commercial plans from requiring a rediagnosis to maintain autism coverage — with Medi-Cal expressly exempt. Texas Medicaid runs the other instrument.

From the Texas Medicaid Provider Procedures Manual, Children's Services Handbook, §2.3.2:

“To be eligible for the ABA services outlined in this section, a diagnosis of ASD complete with diagnostic criteria and symptom severity level from the current DSM must be made or reconfirmed within 3 years of initiation or recertification of ABA services.”

Past three years, it is not a refresh: “a comprehensive re-evaluation of ASD symptom severity levels per DSM criteria must be made by qualifying diagnostic providers … A re-evaluation consists of the same components as an initial comprehensive diagnostic evaluation.”

The turn: the clock is on recertification, so it catches long-standing clients

A rediagnosis requirement at intake is an access problem for new families. A rediagnosis requirement at recertification is a continuity problem for the children you have treated the longest. Texas wrote both into the same sentence, and the second one is the one that goes unnoticed until a recert is denied.

Nothing about this is new, which is the other half of the story. We diffed §2.3 across the September 2025, January, June, August and September 2026 editions of the handbook: it has not changed a character.

What else is in the chapter that gets described wrong

• 85% attendance. Logs must be kept for the child and separately for the parent or caregiver, with the percentage calculated. Below 85%, “additional documentation must be submitted by the LBA to substantiate need for continued ABA services at the previously approved level.”
• Eight hours a day. “Direct treatment for the child or youth is limited to a total of 8 hours per day, inclusive of procedure codes 97153, 97154, 97155, and 97158.” The published weekly bands are guidelines that route you to physician review; this one is a limit.
• Supervision has to be observation. “Only direct supervision, where the LBA directly observes the LaBA or the BT providing services … will be reimbursed.” Case review, data-collection procedures and professional development are named as not reimbursable.
• No separate pay for the paperwork. “Separate reimbursement for treatment planning, note documentation, report writing, or updating of charts and data sheet is prohibited (other than what is allowable under procedure code 97151).”
• “Therapist” is a manual violation. Behavior technicians “may not use the term ‘therapist’ or be referred to as a ‘therapist’ in their job title” with families, caregivers, school staff or physicians.

The limits

This is THSteps-CCP, for clients 20 and younger. The three-year rule is scoped to ABA eligibility, not to the autism diagnosis generally — a child remains autistic; what expires is the paperwork Texas Medicaid will authorize against. And California's ban reaches commercial plans only, so the two rules do not actually collide in any one family's coverage. They land on the same question from opposite directions depending on who pays.

What you must know or do

• Run a report of every Texas Medicaid client by date of ASD diagnosis and flag anyone whose diagnosis turns three before their next recertification. That is the list that will be denied, and the referral for a comprehensive re-evaluation has to be in motion months ahead of it.
• Keep two attendance logs, not one. The caregiver percentage is a separate submission requirement and it is the one practices forget.
• Check what your team bills as 97155. If the LBA was reviewing data rather than observing a session, Texas Medicaid does not pay for it, and that is a recoupment shape.
• Search your job titles, email signatures and website for “therapist” applied to a technician. It costs an afternoon and it is written in the manual.