International Medical Graduates From J1 Waiver through Permanent

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 ◦ 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-1 B � After approval* by USCIS, H-1 B 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-1 Bs 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-1 B Residents �No two year home residence requirement � Employer must file H-1 B to “transfer” physician � Finite number of H-1 Bs 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-1 B � 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-4 s not permitted to work ◦ Security

Visa Bulletin – May 2018 Employm All entbased China – Mainland India Mexico Philippin es 1 st C Jan 01, 2012 C C 2 nd C Sep 01, 2014 May 1, 2008 C C

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 � J 1 – Immigration status of IMGs sponsored by the ECFMG � H-1 B – 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