Is the reverse side inlay coin-aligned or medal-aligned to the front side?
Yes, that is a new development.

FYI, the new Paulson rack chips for Four Queens, Suncoast and Aladdin seem to be randomly aligned, both in insert placement and in obverse-to-reverse alignment. So it appears it's not happening all the time. Is the Casino Aztar you picture a rack chip or a LE? Perhaps Paulson is offering special alignment only if requested (and at additional cost?).