During the 2026 Legislative Session, Florida lawmakers filed Senate Bill (SB) 1130 and House Bill (HB) 1015, a sweeping insurance reform proposal aimed at curbing insurer practices that contribute to delayed payments, improper denials, and administrative barriers for health care providers. While the bill does not amend home health licensure laws or Medicaid statutes, it would significantly reshape the legal and operational landscape governing how insurers reimburse providers across Florida.

At its core, SB 1130/HB 1015 strengthens provider protections by tightening rules around claim downcoding, prior authorization, prompt payment, and retrospective denials, while establishing enforceable rights and remedies when insurers fail to comply with the law.

Addressing Downcoding Practices

SB 1130/HB 1015 creates a new section of law — section 627.4193, Florida Statutes (F.S.) — that directly restricts insurer “downcoding,” defined as altering a billed service code or modifier in a way that reduces payment.

Under the bill, insurers and payment adjudicators are prohibited from downcoding services ordered by an in-network provider unless such action is expressly authorized in the provider’s participation agreement. Even where downcoding is permitted by contract, insurers must first conduct a medical record review and provide detailed advance notice explaining the basis for the coding change and the financial impact.

Importantly, the bill establishes a presumption that a physician’s diagnosis and service order are correct, placing the burden on insurers to verify any alleged coding error. Insurers are made solely responsible for legal violations arising from improper downcoding, and providers are granted a private right of action to seek relief when violations occur.

Major Prior Authorization Reform

SB 1130/HB 1015 substantially rewrites Florida’s prior authorization framework by amending section 627.42392, F.S. The bill requires insurers and utilization review entities to operate transparent, standardized, and timely authorization systems.

Key reforms include mandatory electronic prior authorization platforms, public disclosure of all authorization requirements and clinical criteria, and strict limits on insurers’ ability to change authorization rules without advance notice and contract amendments. Adverse determinations must be made by a Florida-licensed physician of the same specialty as the ordering provider, and detailed explanations must accompany any denial.

The bill also imposes firm timelines for decision-making — 72 hours for standard requests and 24 hours for urgent requests — and provides that services are automatically deemed authorized if insurers fail to meet those deadlines. Once granted, a prior authorization becomes a conclusive obligation to pay, with only narrow exceptions for fraud, ineligibility, or services not rendered.

Strengthening Prompt Payment and Limiting Retroactive Denials

SB 1130/HB 1015 further amends section 627.6131, F.S., Florida’s prompt payment law, to address long-standing provider concerns about delayed reimbursement and post-payment recoupments.

The bill shortens timelines for insurers to pay or deny claims, restricts repeated requests for documentation already provided, and clarifies that once an insurer has access to a patient’s electronic medical record, no additional information may be required to process payment. Interest penalties are imposed on underpaid or improperly denied claims, calculated on the full amount owed.

The bill also tightens limits on retrospective denials and overpayment recoveries, restricting eligibility-based denials to a defined window and prohibiting insurers from offsetting unrelated claims while disputes are pending. Providers retain all existing contractual, statutory, and common-law remedies.

What This Means for Home Health Providers

Although SB 1130/HB 1015 does not amend Chapter 400, F.S, or directly regulate home health agency licensure, it carries meaningful implications for home health providers that bill commercial insurers, self-insured employer plans, or managed care organizations acting as insurers.

Home health agencies frequently encounter challenges such as downcoding of skilled services, unstable prior authorizations, delayed payments, and retrospective denials after care has already been delivered. SB 1130/HB 1015 addresses these issues by creating clearer rules, enforceable timelines, and legal accountability for insurers.

If enacted, the bill would improve payment predictability, reduce administrative burden, and strengthen providers’ ability to challenge improper insurer actions — outcomes that are particularly important for labor-intensive providers that must front payroll costs while awaiting reimbursement.

What the Bill Does Not Do

SB 1130/HB 1015 does not expand Medicaid benefits, alter Agency for Health Care Administration (AHCA) oversight, modify provider licensure requirements, or impose new clinical or operational mandates on health care providers. Instead, it focuses squarely on insurer conduct and reimbursement practices.

This legislation represents one of the most comprehensive provider-focused insurance reforms proposed in Florida in recent years. By restricting downcoding, reforming prior authorization, strengthening prompt payment rules, and creating enforceable rights for providers, the bill seeks to rebalance the payer-provider relationship and improve stability across the health care delivery system.

For home health providers and other health care professionals alike, SB 1130/HB 1015 would not change how care is delivered — but it could significantly change how reliably and fairly that care is paid for.

To view a list of legislation we are monitoring for the upcoming 2026 session, click here.