Your child's autism diagnosis is more than three years old: what Texas Medicaid requires before ABA is recertified
Your child’s autism diagnosis does not expire. The documentation supporting it does, and in Texas Medicaid that is a date rather than a clinical judgment. Two separate re-evaluations sit behind a single recertification, they are completed by different providers, and neither provider is responsible for tracking the other’s calendar.
Nobody sends a notice when the three-year date passes. The authorization clock is held by your ABA provider, the diagnostic clock is held by a clinic that has no reason to know a recertification is coming, and the date itself sits in a report you may not have opened in years. That is a gap in how the two systems are sequenced, not something you were supposed to be tracking on your own.
What a comprehensive diagnostic evaluation has to contain
| Required component | What it establishes | Where it is written |
|---|---|---|
| A diagnosis made or reconfirmed within three years of initiating or recertifying ABA services | That the diagnostic documentation is current at the point of recertification | §2.3.2 |
| The diagnostic criteria and symptom severity level according to the most current edition of the DSM | Which criteria the child meets, and at what level of support need | §2.3.2 |
| A reliable, valid, standardized diagnostic assessment tool, or combination of tools, in its current edition, appropriate to the child’s age, and indicated for diagnostic purposes by its publisher | That the diagnosis rests on a validated instrument rather than a screener | §2.3.2 |
| Documentation of the child’s age, the date of the initial ASD diagnosis, any known comorbid behavioral or physical health conditions, and trauma history | The clinical context the diagnosis sits inside | §2.3.2 |
| The standardized tool must have been a part of the evaluation or re-evaluation | That the instrument sits inside the evaluation rather than standing in for it | §2.3.7.2 |
| A re-evaluation consisting of the same components as an initial comprehensive diagnostic evaluation | That nothing lighter substitutes once the evaluation is more than three years old | §2.3.2 |
The last row is the one families are least often told about:
A re-evaluation consists of the same components as an initial comprehensive diagnostic evaluation.
Not a signature on a form, and not a letter from the pediatrician. The full evaluation process again.
Requirement 1: a diagnosis made or reconfirmed within three years
That rule is in the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, §2.3.2. If the original comprehensive diagnostic evaluation is more than three years old, Texas Medicaid requires a comprehensive re-evaluation of symptom severity by a qualifying diagnostic provider. The window runs from that evaluation, a different document from anything the ABA team produces.
Where this goes wrong: the three years get counted from the date ABA started, and the diagnostic evaluation underneath it turns out to be older.
Requirement 2: the standardized diagnostic assessment tool
Texas Medicaid defines a comprehensive diagnostic evaluation as "the entire process of gathering information to determine a diagnosis, which must include a reliable, valid, standardized diagnostic assessment tool" (§2.3.2). Elsewhere the manual says a standardized tool "must have been a part of" the evaluation or re-evaluation (§2.3.7.2).
The manual names the Autism Diagnostic Observation Schedule, the Autism Diagnostic Interview-Revised, and the Childhood Autism Rating Scale as examples, and requires the tool be indicated for diagnostic purposes by its publisher.
Screening tools do not count: the manual specifically excludes instruments like the STAT and the M-CHAT-R from replacing a validated diagnostic assessment tool.
Requirement 3: the DSM criteria and severity level, stated in the report
The ADOS is one of the tools the manual names, so it satisfies the standardized-tool component and nothing beyond it. A report with scores and no DSM criteria or severity level has satisfied one requirement out of several.
An ADOS score is not a DSM severity level.
The ADOS-2 produces a comparison score, sometimes called a calibrated severity score, on a 1 to 10 scale comparing a child’s symptoms to those of other children with autism of the same age and language level (Hus and Lord, Journal of Autism and Developmental Disorders, 2014). DSM severity is a different construct: Level 1, 2, or 3, rated separately for social communication and for restricted and repetitive behaviors, based on the support the child needs.
The two are not interchangeable, and the research literature is explicit that the relationship between them has not been established (Journal of Autism and Developmental Disorders). Domain-level severity scores for the ADOS-2’s social affect and restricted/repetitive behavior scales exist in academic publications but not in the instrument’s own manual, so many clinicians have never used them.
The ADOS-2 also applies a single combined cut-off rather than separate thresholds for the two DSM criteria, so a child can reach an ADOS-2 classification of autism spectrum on social communication symptoms alone, without meeting the DSM’s restricted and repetitive behavior criterion (Evers, Maljaars, et al., European Child & Adolescent Psychiatry, 2021;30:75-87). The instrument was never designed as a stand-alone diagnostic measure.
None of this is an argument against the ADOS. It is well validated and part of what most evaluators consider the gold standard. The point is narrower: "we will run an ADOS" is not the same answer as "we will complete a comprehensive diagnostic evaluation."
Where this goes wrong: the report arrives with a classification and scores, the DSM criteria and severity level are nowhere in it, and the omission is discovered at recertification rather than at the appointment.
Requirement 4: a qualifying diagnostic provider
Texas Medicaid recognizes these providers as qualified to diagnose or re-evaluate ASD:
- A developmental pediatrician
- A neurologist
- A psychiatrist
- A licensed psychologist
- An interdisciplinary diagnostic team
An interdisciplinary team may be led by a physician or an allowed practitioner, meaning a physician assistant, certified nurse practitioner, or clinical nurse specialist licensed in Texas, coordinating with autism specialists: a licensed clinical social worker, licensed professional counselor, licensed psychological associate, licensed specialist in school psychology, occupational therapist, or speech-language pathologist. Each provider administering a diagnostic element must be licensed to use the standardized tool involved.
The list does not include a general pediatrician or a behavior analyst. The re-evaluation is a diagnostic activity, so your ABA provider cannot complete it for you, and these are the specialists with the longest waitlists in most Texas markets.
Where this goes wrong: the request goes to the general pediatrician because that appointment is available first, and the scheduling clock restarts weeks later.
Requirement 5: the ABA re-evaluation, which is a separate document
Texas Medicaid uses "re-evaluation" for two separate things at recertification, and the vocabulary works against families.
The diagnostic re-evaluation is the one described above, performed by one of the providers in that list.
The ABA re-evaluation is a different document, performed by the licensed behavior analyst overseeing your child’s therapy. It covers all components of the initial ABA evaluation that fall within that provider’s scope of practice, an updated behavior support plan where applicable, and baseline, current, and interim data for every behavior and skill targeted (§2.3.7.8).
It also carries a requirement that shapes what your child’s therapy team documents all year: it must allow a reviewer to assess whether your child’s behavior and skills have improved to a clinically meaningful extent in at least two settings. The manual gives examples: home, the community, or with different family members or peers. Progress visible only in a single therapy setting is not what recertification is built to demonstrate.
Both have to be in place. Current diagnostic documentation with no ABA re-evaluation does not meet the requirement, and neither does an ABA re-evaluation attached to a four-year-old diagnostic evaluation.
Where this goes wrong: the two documents are treated as one, usually because both are called a re-evaluation, and the diagnostic side is never scheduled.
Requirement 6: the recertification dates
Texas Medicaid measures the three-year window for recertification against the date of the ABA re-evaluation, not the date you submit paperwork (§2.3.7.7). The ABA re-evaluation may be performed no earlier than the last 60 days of the current authorization period (§2.3.7.8). A recertification request is timely when submitted within 30 days before the authorization period ends.
A request submitted after the current authorization end date is denied for all dates of service before the date the request was received (§2.3.11.4).
If the diagnostic documentation is the stale piece, it has to be resolved first, and it has the least predictable timeline.
Where this goes wrong: the diagnostic appointment is booked after the ABA re-evaluation is already underway, and the specialist’s first available date falls outside the 30-day submission window.
Eligibility, medical necessity, and the attendance expectation
Texas Medicaid covers ABA for children and youth 20 years of age or younger, and a diagnosis alone is not sufficient to establish medical necessity. The clinical documentation has to show that ABA therapy is medically necessary to treat, correct, or ameliorate the child’s condition.
A second requirement surprises families more than the diagnosis rule does: an attendance expectation of at least 85 percent of scheduled sessions, applied to both the child’s sessions and the parent or caregiver sessions. We will cover it separately.
What to check
- The date of your child’s most recent comprehensive diagnostic evaluation. Not the date ABA started, and not the date of the last ABA progress review.
- That date plus three years, written next to the date of your next expected recertification.
- Whether the most recent report states the DSM diagnostic criteria met and the DSM symptom severity level, and not only the results of a standardized tool.
- Which standardized diagnostic assessment tool the report names, and whether it was the current edition and appropriate to your child’s age at the time.
- Whether the report documents your child’s age, the date of the initial ASD diagnosis, known comorbid conditions, and trauma history.
- The credential of the provider who completed it, checked against the qualifying provider list above.
- The office that completed the original evaluation, called first, since it already holds the diagnostic history. Ask for a comprehensive diagnostic re-evaluation for ASD, and confirm the report will document the DSM diagnostic criteria met and the DSM severity level. Naming the requirement precisely reduces the chance you are scheduled for something incomplete.
- The current authorization end date, the 60-day window before it, and the 30-day submission window, all three on one calendar.
- Your child’s ABA team told the date of the diagnostic evaluation, so they can sequence the ABA re-evaluation around it.
- Your own copy of the completed evaluation, held outside any provider’s file.
Frequently asked questions
Does an autism diagnosis expire for Texas Medicaid ABA coverage?
An autism diagnosis itself does not expire for Texas Medicaid, but the documentation supporting it must be current. The Texas Medicaid Provider Procedures Manual, Children's Services Handbook §2.3.2, requires the autism diagnosis, including DSM criteria and symptom severity level, to have been made or reconfirmed within three years of initiating or recertifying ABA services.
Is a Texas Medicaid autism re-evaluation the same as a full new evaluation?
A Texas Medicaid autism re-evaluation has the same scope as a full initial evaluation. The Children's Services Handbook states that a re-evaluation consists of the same components as an initial comprehensive diagnostic evaluation, including a reliable, valid, standardized diagnostic assessment tool and a current DSM symptom severity level.
Who can perform an autism re-evaluation for Texas Medicaid ABA recertification?
Under Texas Medicaid, an autism re-evaluation for ABA recertification can be performed by a developmental pediatrician, neurologist, psychiatrist, licensed psychologist or a qualifying interdisciplinary diagnostic team. A behavior analyst delivering ABA therapy cannot perform the diagnostic re-evaluation.
Is an ADOS enough for Texas Medicaid ABA authorization?
An ADOS is not enough by itself for Texas Medicaid ABA authorization. Texas Medicaid requires a comprehensive diagnostic evaluation, defined as the entire process of gathering information to determine a diagnosis, which must include a standardized diagnostic tool. The ADOS satisfies the standardized-tool part, and the evaluation must also document the DSM diagnostic criteria and symptom severity level, the child's age, the date of initial diagnosis, comorbid conditions and trauma history.
Is an ADOS-2 comparison score the same as a DSM severity level?
An ADOS-2 comparison score is not the same as a DSM severity level. The ADOS-2 comparison score is a 1 to 10 metric comparing a child's symptoms to other children with autism of the same age and language level. DSM severity is expressed as Level 1, 2 or 3, rated separately for social communication and for restricted and repetitive behaviors, based on support needs. The research literature treats the two as distinct constructs whose relationship is not established.
Can an ADOS-2 classification substitute for a DSM diagnosis?
An ADOS-2 classification cannot substitute for a DSM autism diagnosis. The ADOS-2 algorithm uses a single combined cut-off rather than separate thresholds for the two DSM criteria, so a child can meet an ADOS-2 autism spectrum classification on social communication symptoms alone without meeting the DSM's restricted and repetitive behavior criterion. The ADOS-2 was not designed as a stand-alone diagnostic measure.
Can a screening tool like the M-CHAT be used instead of a full diagnostic assessment?
A screening tool like the M-CHAT cannot be used instead of a full diagnostic assessment for Texas Medicaid. Texas Medicaid specifically states that screening tools such as the STAT or M-CHAT-R may not replace a validated diagnostic assessment tool.
What happens if a Texas Medicaid ABA recertification request is submitted late?
Under the Texas Medicaid Provider Procedures Manual, §2.3.11.4, an ABA recertification request submitted after the current authorization period ends is denied for all dates of service before the date the request is received. A recertification request is considered timely when it is submitted within 30 days before the authorization period ends.
Does the three-year rule apply to private insurance ABA coverage?
The three-year diagnosis requirement comes from Texas Medicaid policy, not from private insurance. Private and employer plans set their own ABA authorization criteria, so check directly with the plan.
Not sure where your authorization stands?
Our care team can walk you through the timeline and what your next recertification will ask for.
Forta provides Online ABA therapy in 47 states, and In-Home ABA therapy in select cities including Houston, TX.
Sources
- Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, §2.3 Autism Services, August 2026 edition. Link
- Evers K, Maljaars J, et al. "How well are DSM-5 diagnostic criteria for autism spectrum disorder represented in standardized diagnostic instruments?" European Child & Adolescent Psychiatry, 2021;30:75-87. Link
- "Brief Report: DSM-5 ’Levels of Support’: A Comment on Discrepant Conceptualizations of Severity in ASD." Journal of Autism and Developmental Disorders. Link
- Hus V, Lord C. "The Autism Diagnostic Observation Schedule, Module 4: revised algorithm and standardized severity scores." Journal of Autism and Developmental Disorders, 2014. Link
About this article
Written by Megan Butler, VP of Clinical Operations · Clinically reviewed by Crista Conboy, MA, BCBA · 2026-08-27
What this is. A plain-language walkthrough of what the Texas Medicaid provider manual requires, with a link to the manual itself. It covers ABA therapy delivered through Texas Medicaid under the Texas Health Steps Comprehensive Care Program, and it is not a statement about what your plan will approve. If your child’s ABA therapy runs through a private or employer plan, different rules apply. Confirm anything here with your child’s clinical team and your plan before you act on it.
