## Facts

- Mary D. Stinemetz was a Kansas resident enrolled in the Kansas Medical Assistance Program (Medicaid), which was administered by the Kansas Health Policy Authority (KHPA).
- Stinemetz had end-stage liver disease and needed a liver transplant.
- Stinemetz was a practicing Jehovah’s Witness for decades and objected, on religious grounds, to whole-blood transfusions and related procedures inconsistent with her faith.
- A “bloodless” liver transplant technique was medically accepted and would comply with Stinemetz’s religious beliefs; evidence indicated it could be less expensive than a transplant involving transfusions.
- Kansas Medicaid would pay for a liver transplant in Kansas, including a bloodless liver transplant if available in-state, but no Kansas hospital offered the bloodless technique.
- The Nebraska Medical Center in Omaha (and other out-of-state facilities) could perform the bloodless transplant Stinemetz sought.
- Kansas Medicaid rules limited payment for non-emergency out-of-state care occurring more than 50 miles from the Kansas border unless KHPA granted prior authorization.
- Stinemetz requested prior authorization for an out-of-state bloodless liver transplant in Omaha.
- KHPA denied the request, reasoning that Stinemetz’s religious objection to transfusions did not constitute “medical necessity” under the out-of-state authorization criteria.
- Stinemetz sought judicial review, alleging violations of the Free Exercise Clause of the First Amendment and § 7 of the Kansas Constitution Bill of Rights; the district court affirmed KHPA, and Stinemetz appealed.

## Issues

1. Whether KHPA’s denial of prior authorization for an out-of-state bloodless liver transplant violated Stinemetz’s right to free exercise of religion under the First Amendment.
2. Whether KHPA’s denial violated § 7 of the Kansas Constitution Bill of Rights.
3. Whether, under the Kansas Judicial Review Act (KJRA), KHPA’s decision was unlawful as applied in light of these constitutional protections.

## Decision

- The Kansas Court of Appeals reversed the district court and held that KHPA’s denial violated Stinemetz’s free-exercise rights under both the First Amendment and § 7 of the Kansas Constitution Bill of Rights.
- The court determined that, although the Medicaid regulations were facially neutral, the regulatory structure allowed KHPA to make case-by-case exceptions for out-of-state services, creating a system of individualized determinations.
- Because a discretionary exemption scheme existed, KHPA could not deny an exception for a religious hardship without a compelling reason; KHPA did not carry that burden on this record.
- Under § 7, the court found Stinemetz’s beliefs sincere and concluded the denial burdened her religious exercise by forcing a choice between violating her faith, foregoing a potentially life-saving transplant, or paying privately for treatment Medicaid would cover if available in Kansas.
- The court rejected KHPA’s asserted justifications (including cost control and uniform administration) as insufficient as applied, noting evidence that the bloodless technique was medically accepted and could be less expensive.
- The court concluded KHPA failed to show that denying authorization was the least restrictive means, particularly because Medicaid would pay for a transplant for Stinemetz in Kansas and would pay for a bloodless transplant if Kansas offered it.
- The case was remanded with directions consistent with the court’s constitutional rulings.

## Legal Principles

- Under the KJRA, appellate courts review the agency action under the same limited framework used by the district court; whether a statute or regulation is constitutional as applied is a question of law reviewed without deference.
- Administrative agencies cannot finally decide constitutional questions; constitutional challenges may be raised in court review of agency action.
- Under the First Amendment, a neutral and generally applicable rule ordinarily does not require a compelling governmental interest even if it incidentally burdens religion; however, when the government maintains a mechanism for individualized exemptions, it may not refuse an exemption for religious hardship without a compelling reason.
- Section 7 of the Kansas Constitution Bill of Rights provides greater protection for religious exercise than the First Amendment in this context and applies a strict-scrutiny framework when state action burdens sincere religious exercise.
- The § 7 analysis asks: (1) whether the claimant’s religious beliefs are sincerely held; (2) whether state action burdens free exercise; (3) whether the State has an overriding/compelling interest; and (4) whether the State used the least restrictive means; the claimant bears (1) and (2), and the State bears (3) and (4).

## Conclusion

The Kansas Court of Appeals held that KHPA’s refusal to authorize an out-of-state bloodless liver transplant imposed an unconstitutional burden on a Medicaid beneficiary’s sincere religious practice and, given KHPA’s discretionary exception process and the availability and cost evidence for the bloodless technique, the denial could not survive strict scrutiny under either the First Amendment or § 7 of the Kansas Constitution.


Stinemetz v. Kansas Health Policy Authority, 252 P.3d 141 (2011)