International Medical Graduates – From J-1 Waiver through Permanent Residence Mary E. Ryan

J-1 Waivers Purpose: Bring physicians into medically underserved communities Ensure that low income populations are served Keep physicians in the community to permanently address shortages

IMG J-1 Residents J-1 Two year home residence requirement Waiver of HRR Interested Government Agency (IGA) based on service in a medically underserved area Conrad State 30 program Federal Programs: Delta Regional Authority Appalachian Regional Commission Department of Health and Human Services

J-1 Waivers Primary Care/Specialists Programs favor primary care and Federal programs are generally limited to primary care Specialists permitted under Conrad 30 May require additional documentation May be accepted only after primary care applications are accepted

J-1 Waivers Generally for all IGA programs Conrad 30 – State Program Worksite(s) in Federally designated medically underserved areas – HPSA/MUA http://www.hrsa.gov/shortage/find.html Conrad 30 – State Program State may permit up to 10 Flex spots Prepare to show service to patients in underserved areas May be considered only after waivers for HPSA/MUA Multiple sites - if one is not in HPSA/MUA – need FLEX

J-1 Waivers 3 year contract Full-time/ minimum 32 hours direct patient care Address of worksites No non-compete Statement re: compliance with J-1 policies by both parties to the contract Service to low income Compliance with prevailing wage obligation Start within 90 days of receipt of waiver

J-1 Waivers Generally applications require: 6 or more months of evidence of unsuccessful recruitment Evidence of facility’s patient mix: Commercially insured Medicaid/Medicare Sliding Fee Public notice that all patients will be seen regardless of ability to pay

J-1 Waivers Procedures: Physician obtains Waiver case number from DOS Employer/physician submit waiver application to the State 30 administrator* State recommends waiver and sends to DOS DOS recommends waiver and sends to USCIS USCIS approves waiver * Delaware requires advance employer application

J-1 to H-1B After approval* by USCIS, H-1B petition filed by employer with USCIS (* possible to file with DOS recommendation) Upon approval of H petition and change of status, physician commences employment Reports arrival to practice to the State Yearly confirmations of continued employment Changes in practice site/contract must be reported to State and to USCIS

Extenuating Circumstances H-1Bs with J-1 waiver may transfer to new employer if extenuating circumstances Extenuating defined on case-by-case basis Not “counted” again Direct filing with USCIS possible Obtaining State approval bolsters transfer request. Must complete full 3 years of service before change to other status

IMG H-1B Residents No two year home residence requirement Employer must file H-1B to “transfer” physician Finite number of H-1Bs available each year for cap-subject employers Cap-exempt – non-profit organizations affiliated with an institution of higher education Six year limit May need to initiate permanent residence immediately

Beyond Waivers/H-1B Permanent Residence a/k/a “Green Card” Request may arise during contract negotiations Why? Long wait for visas – India/China Ability for spouse to obtain work authorization Currently H-4s not permitted to work Security

Visa Bulletin – May 2018 Employment-based All China – Mainland India Mexico Philippines 1st C Jan 01, 2012 2nd Sep 01, 2014 May 1, 2008

Green Card Process Establish basis by filing immigrant petition Employment/Family Application to register permanent residence Physicians must complete 3 year J-1 service obligation before filing unless National Interest Waiver Spouse and children are derivative beneficiaries Interim travel and work benefits

Permanent Labor Certification/Immigrant Petition Employer must file labor certification with Department of Labor Must provide evidence of unavailability of U.S. workers Specific recruitment procedures must be followed Employer files immigrant petition with USCIS based on approval of labor certification Physician files application to register permanent residence 3 year service obligation completed Visa available

Physician National Interest Waiver Immigrant Petition with USCIS Must be based on 5 year contract for work in underserved area Dated less than 6 months before filing Typically amend J-1 service contract; add 2 years Must obtain support letter from State May file application to register permanent residence even if 3 year obligation not completed if visa available Must complete 5 years to obtain green card

Understanding the concerns of IMGs Timing Strictures of immigration system Cost of mistakes Must plan for the future now

What you can do Create certainty by: Having policies and procedures set up before you recruit IMGs that meet the requirements of waivers and beyond – 3 year contract/no non-compete, little flexibility in work sites Swift execution of requirements Establish clear policies on whether and what avenues you will pursue for permanent residence

Important Terminology IMG: International Medical Graduates ECFMG: Educational Commission on Foreign Medical Graduates J1 – Immigration status of IMGs sponsored by the ECFMG H-1B – Immigration status of IMGs not sponsored by the ECFMG J-2 – Spouse of J-1 Conrad 30: State Administered J-1 Waiver program DOS – U.S. Department of State USCIS – U.S. Citizenship and Immigration Services

Taylor & Ryan, LLC Mary E. Ryan Taylor & Ryan, LLC 1777 Reisterstown Road, Ste. 265 Baltimore, MD 21208 mryan@taylor-ryan.com 410.412.3467