TALLAHASSEE -- While the rest of the country talks about or acts on expanding Medicaid coverage, it’s still off the table in Florida. In fact, Florida legislators are moving in the opposite direction.

As they hash out an approximately $90 billion budget, leaders in both the Republican-controlled House and Senate are considering permanently shortening the time period for retroactive payment of hospital bills and debating whether to push more privatized care for people with disabilities. They’ve also considered implementing work requirements for people on the program, not unlike those already being used for temporary cash assistance.

Though other states have pursued similar policies, with some recently challenged in federal court, Florida stands alone because of its reluctance to expand Medicaid. Every other state that has secured federal permission to implement such changes has also expanded Medicaid coverage to childless able-bodied adults.

“We are seeing this continuing trend of states coming into expansion and states debating expansion,” said MaryBeth Musumeci, the associate director for the Kaiser Family Foundation’s Program on Medicaid and the Uninsured. “Florida has not.”

Amid these changes, Democrats, who sought and failed to get a single hearing on Medicaid expansion in the Legislature this year, are looking anew to an ongoing effort to put Medicaid expansion on the 2020 ballot. Thirty-six states and the District of Columbia have expanded who is covered under the program.

Both the House and the Senate are expected to agree on at least one issue: extending a policy change that would shorten how long patients can retroactively have bills covered after applying for Medicaid.

The change — which would reduce the state Agency for Health Care Administration’s budget for Medicaid coverage by $104 million, including federal funds — would restrict how long patients can have Medicaid cover their bills to at most the calendar month before their application date. The prior policy allowed patients to have the program cover healthcare costs up to three months before the date they applied for coverage, though the change only affects seniors and those with disabilities. Pregnant women and children are exempted.

Though the Legislature initially voted to shorten the window in 2018, the policy went into effect in February after the federal government approved the change last November. The policy requires the Legislature to approve the change again for it to remain in effect going into July.

The House has moved to shorten that period permanently, while the Senate, in an effort to appease concerned advocates, has advanced measures that would either extend the policy for another year or match the House’s permanent change.

Agency for Health Care Administration officials, including its new leader Mary Mayhew, have cast the change as an incentive for people to sign up for the program sooner.

But advocates, including Anne Swerlick of the Florida Policy Institute, have contended that sentiment “ignores the reality of Florida’s Medicaid program.”

Under the new rules, Swerlick told a committee last month, someone who qualifies to be covered by Medicaid on the last day of the month, such as in the case of a catastrophic injury, would only be allowed to have costs retroactively covered for the calendar month in which they apply. If they applied even a day afterward, “those thousands of dollars of emergency room bills will not be paid,” she said. “You were unlucky enough to end up in the hospital on the last day of the month.”

“Ultimately those costs are going to be borne by all of us: higher insurance premiums, higher hospital costs, and of course more uncompensated care costs,” she added.

A budget proposal in the House — which is being discussed with the Senate — could also dramatically change how the state’s Agency for Persons with Disabilities manages Medicaid coverage for those on its rolls. Though the Legislature determines its budget, the agency came under fire earlier this session for having run deficits in recent years.

If it does so again this fiscal year, the House’s plan would require the agency to work with the the Agency for Health Care Administration to rework the waiver it operates under with the federal government.

That plan could stand to dramatically change how the agency provides coverage to the about 34,000 people with intellectual and developmental disabilities. Unlike most of the state’s other Medicaid programs, it is one of the few that is not run through the state’s Medicaid managed care program, in which the state contracts with private organizations to manage people’s healthcare.

The House has also been advancing work requirements for Medicaid — a policy supported by DeSantis and a long-time conservative wish list item — though the Senate has not heard the proposal this year.

The bill in the House would require an estimated 500,000 people in the program to work or show they are trying to do so to keep their coverage, and would mirror existing requirements already used for a temporary cash assistance program. The requirements would not apply to children, who disproportionately are covered by Medicaid, or to those who have long-term care coverage in the program, like those in nursing home facilities. It also would not likely to people who get disability income through Social Security.

On House leaders’ legislative agenda, the item has nevertheless been outranked by sweeping changes to the state’s regulations on healthcare facilities, including removing certificate of need laws and extending time constraints on outpatient surgery centers.

Senators, including President Bill Galvano, had said for a few weeks they were open to considering requirements. But it’s now “very doubtful” the Senate agrees to the proposal this session, said Sen. Aaron Bean, R-Fernandina Beach, the chamber’s healthcare budget chief.

Bean noted he has sponsored work requirement bills in the past but cited time constraints and acknowledged intervening disagreements the chambers had had on how to handle budget versus policy. “I just think it’s late in the ballgame without a bill, a vehicle, without it being talked about.”

He also nodded to a series of other substantial policy changes lawmakers still have to make in either or both chambers: a proposal to import prescription drugs from Canada, House Speaker José Oliva’s bookmarked certificate-of-need repeal for hospitals, changes that would promote e-prescribing: “There’s just so many big things in healthcare this year. Maybe next year, maybe this summer, we’ll look at it.”

Bean did add one asterisk: “Unless it’s being traded at the President’s level and the Speaker’s level, when there’s talk of that nature, big things could happen.”

Top leaders are certainly negotiating how to compensate hospitals for Medicaid care, said Bean, referring to the long-recurring debate on an additional $318 million that about two dozen facilities with the highest Medicaid caseloads receive yearly in addition to a general “base rate.”

“That’s something they’re working out,” Bean said of Galvano and Oliva.

One snag in the Legislature’s consideration of retroactive eligibility and work requirements, however, could come from the courts. A federal court last month knocked down recent changes in both Arkansas and Kentucky that instituted work requirements and included retroactive eligibility changes, even though both have expanded the safety net program. Other states have waivers for such changes still pending.

Democrats, still in the minority, have little power to halt such measures or to advance their desires to expand the Medicaid population in Florida.

Rep. Nicholas Duran, D-Miami, who helped carry a proposed expansion bill this year that did not receive a single hearing, acknowledged the chances his proposal was heard this year were “zero.” But he intends to bring the same proposal, which would include work requirements in addition to expanding the Medicaid population, next year, he said.

“Is the likelihood of us entertaining that high? Probably not,” he admitted. “But I’ve seen crazier things happen in the Legislature.”

On the cusp of 2020, Democrats are also turning instead to pursuing Medicaid expansion through a voter referendum, which would unequivocally task state leaders with expanding eligibility to people who earn up to 138 percent of the federal poverty level.

Even Mayhew — a staunch opponent of expansion — has acknowledged she’d implement it if passed.

A political committee has gathered more than 35,000 of nearly 77,000 needed signatures to meet the first threshold for a constitutional amendment that would require the state to pursue Medicaid expansion. The effort would need more than 766,000 total signatures to ensure voters decide the issue on the ballot.

“We have a year before the next election, and I know between now and then there’s a lot of people looking at the voter referendum as a vehicle,” Duran acknowledged. He also acknowledged that the referendum campaign would struggle under a simultaneous proposal moving through the Legislature that would require 66 percent, rather than 60 percent, of voters to approve any future state amendments.

“It just raises the stakes and the need for a very well coordinated campaign. Starting at 60 percent is a big mountain. Going to 66 percent is an even bigger mountain,” he said. “It’s getting to 10,000 feet and saying, ‘wow, that was hard to get there,’ then looking up and seeing you’ve got 4,000 more feet to go.”