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The Doctor Job presents: Demystifying the J-1 Visa Waiver Process for Physicians

Demystifying the J-1 Visa Waiver Process

If you are a foreign medical school graduate (FMG) who is not a U.S. Citizen, and you are seeking further medical training in the U.S., a J-1 Visa (Education Exchange Visa) will enable you to pursue that training. While a J-1 Visa is fairly easy to obtain, the drawback to this visa is that it requires you to return to your home country at the end of your training for at least two years before being eligible to come back to the U.S. and apply for immigrant status.

If you do NOT want to fulfill the two-year home residency requirement, you do have the option of pursuing a J-1 Waiver (also known as a J Waiver), allowing you to remain in the U.S. Obtaining a J1 Waiver, however, is extremely competitive and requires diligence, patience, and sometimes a bit of luck.

STEP ONE: EVALUATE YOUR J-1 WAIVER OPTIONS

Let’s start by outlining the three methods by which an FMG with a J-1 Visa may obtain a waiver.

1. The Hardship Waiver

If returning to your home country would impose “exceptional hardship” on you, your spouse (who must be a U.S. Citizen or Permanent Resident) or your children, you may be eligible for a hardship waiver. Examples of situations that might qualify as “hardship scenarios” include: an FMG whose immediate family would be forced to separate as a result of the home residency requirement, an FMG who would have to return to a war-torn country, or an FMG with a family member suffering from a disease for which treatment is not available in the home country.

2. The Asylum Waiver

Your foreign residency requirement may be waived by the INS if it is determined that you cannot return to your home country because of persecution you would be likely to encounter, based on race, religion or political opinion.

3. The Interested Government Agency (IGA) Waiver

This is by far the most common J1 waiver obtained by FMGs, and it is also easier to obtain than the hardship or asylum waiver. But that doesn’t mean it’s easy. To obtain an IGA waiver, an agency of the U.S. Government must write to the USIA (United States Information Agency) requesting a waiver of the foreign residency requirement in exchange for the FMG committing to work in a medically underserved area full-time for three years. If the USIA and the INS agree with the agency’s recommendation (which they typically do), the J1 waiver will be granted.


**Note: it is possible to apply for a hardship/asylum waiver and an interested government agency waiver at the same time. If you believe you may be eligible for either a hardship or asylum waiver, this may be advisable in order to increase your odds.


There are currently 4 government agencies that act as IGAs to sponsor J-1 Waivers:
The Appalachian Regional Commission (ARC)
The Delta Regional Authority (DRA)
The Department of Health and Human Services (DHH)
The Veterans Administration (VA)
In addition, individual states are authorized to act as an IGA and sponsor up to 30 physicians each year through a program called the Conrad 30.

DEFINING A MEDICALLY UNDERSERVED AREA

If you have decided to pursue a J1 waiver through an Interested Government Agency, it is important for you to understand what constitutes a medically underserved area. There are two terms that crop up frequently: MUA (medically underserved area) and HPSA (health professional shortage area).

As you begin researching the requirements of IGAs, you will find that some mandate that a physician with a J-1 Visa work in an HPSA, others require a physician with a J-1 Visa to work in an MUA, and still others will sponsor physicians working in either an MUA or HPSA.

HPSA, MUA, MUP: What’s the Difference?

Health Professional Shortage Areas (HPSA) may have shortages of primary medical care, dental or mental health providers and may be urban or rural areas, population groups or medical or other public facilities.

Medically Underserved Areas (MUA) may be a whole county or a group of contiguous counties, a group of county or civil divisions or a group of urban census tracts in which residents have a shortage of personal health services.

Medically Underserved Populations (MUP) may include groups of persons who face economic, cultural or linguistic barriers to health care.

Determining how a particular region and/or healthcare facility is categorized can be a complicated task. Determining an MUA involves application of the Index of Medical Underservice (IMU) to data on a service area to obtain a score for the area. The IMU scale is from 0 to 100, where 0 represents completely underserved and 100 represents best served or least underserved. Under the established criteria, each service area found to have an IMU of 62.0 or less qualifies for designation as an MUA.

Is your head spinning yet? Luckily, there are some valuable resources in place to help you pinpoint which areas fall under MUA or HSPA designation.
The U.S. Department of Health & Human Services has a website (http://hpsafind.hrsa.gov/HPSASearch.aspx) that enables you to search for HPSAs nationwide.
Many states list MUA-designated counties on their government websites.
3Rnet (www.3rnet.org) also contains information regarding underserved communities.

Once you have decided which state you will be applying to work in, and which agency you will be applying through, you can turn to these sites to help determine where to apply for J1 Waiver positions.

STEP TWO: FAMILIARIZE YOURSELF WITH IGA OPTIONS

Since the IGA waiver is the most common for physicians with J1 Visas, the remainder of this article will discuss the process for obtaining an IGA waiver and finding employment in an MUA or HPSA.

Here is a brief summary of the agencies that currently sponsor J Waivers.

The Appalachian Regional Commission (www.arc.gov)

Physicians receiving these J waivers must practice for at least three years in rural Appalachian areas that are designated as Health Professional Shortage Areas (HPSA) by the U.S. Public Health Service (see above for information regarding Health Professional Shortage Areas vs. Medically Underserved Areas). The ARC program is limited to physicians who have completed residency training in a primary care field, which is generally defined as internal medicine, family practice, general practice, pediatrics, general psychiatry or obstetrics and gynecology.

Requests for J waivers under the ARC J-1 Visa Program must be sponsored by a state within the Appalachian Region, which includes all of West Virginia and parts of 12 other states: Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia. All inquiries should be made to state contacts. This means that you apply through the state health department rather than directly to the ARC.

Delta Regional Authority (www.dra.gov)

The Delta Region comprises counties from eight states: Alabama, Arkansas, Illinois, Kentucky, Louisiana, Mississippi, Missouri, and Tennessee. Eligible physicians with J-1 Visas who have completed a residency in Family Practice, General Pediatrics, Obstetrics, or Internal Medicine are eligible for a J Waiver. Candidates can work in an area with either HPSA, MUA, or MUP designation.

The Department of Health and Human Services (www.hhs.gov)

The DHHS serves as the IGA for underserved communities outside of Appalachia. Physicians must provide out-patient primary care (family practice, general internal medicine, general pediatrics, or obstetrics/gynecology) or general psychiatric services. HHS will only process an application for a J1 waiver from a facility in or with a health professional shortage area (HPSA) score of 14 or higher.

The Veterans Administration (www.va.gov)

The VA sponsors physicians for J waivers, but only when they are directly employed by VA facilities. Positions at VA facilities are not subject to MUA or HPSA designation requirements. The VA waiver is often the J1 waiver of choice for specialist physicians, since most other waiver programs are available only to primary care or psychiatric physicians.

State Departments of Health (through the Conrad State 30 Program)

Each individual state can sponsor up to 30 J-1 Waiver applicants per year to work in an underserved area. Most states provide information on their J waiver application and requirements online; however, some states have yet to implement a formal waiver application process. Below you will find links to each state’s website where you can research whether the state you are interested in participates in the Conrad 30 (if not, you may still be able to work in that state through one of the other agencies above).

J-1 Waivers offered through the Conrad 30 are provided on a first-come, first-served basis, so it is a good idea to apply early. A new set of 30 waivers becomes available at the first of each new fiscal year, which begins October 1st in most states (although some states begin on another date). In states that heavily utilize the Conrad 30 program, all of the waivers might be taken within the first four or five months of the fiscal year. In other states, there may be waivers left over at the end of the year.

An important thing to note about the Conrad 30 is that the program is administered differently from state to state. For that reason, it is important that physicians with J-1 visas carefully research the state or states they’re interested in practicing in before embarking on the J-1 waiver application process.

STEP THREE: RESEARCH & SELECT A STATE

Common sense would tell you that the more willing you are to relocate anywhere in the U.S., the greater the chance you will have of obtaining a J-1 waiver position. However, given the complexity of the J Waiver application process, it would be time consuming, frustrating, and ultimately detrimental to cast a wide net.

Here a just a few examples of the differences between states with regard to J Waiver rules and regulations:
Some states begin their new fiscal year beginning in October, while others begin in August or January. Depending on when you can submit your application, this can drastically affect your odds of receiving a waiver.
Some states do not sponsor waivers for specialist physician J-1 Visa holders, while others sponsor anywhere from 5 to 15.
Some states/agencies require that you complete your residency or fellowship program prior to submitting your application, while others only require that you be enrolled at the time you apply. In a similar vein, some states require that your license application just be submitted, while others require that it be fully processed.
Some states may have a fairly streamlined application process, while other states are new participants in the J-1 Waiver program and therefore may not have set procedures in place.
Some states/agencies only recognize HPSA designation while others only recognize MUA designation. Some states recognize both.
Some states/agencies require a personal statement.
Some states/agencies require several letters of recommendation.
These are just a few of the discrepancies you will find. Because the rules are so disparate between states, you need to narrow down your options to one or two states and become an expert in those states’ waiver regulations.

Some things to consider when choosing a state to apply for a J-1 Visa Waiver:

How many underserved areas are in that state? Some states have more MUAs or HPSAs than others.
Does the state have opportunities for specialists or only primary care physicians? If they do sponsor specialists, what is the maximum number of specialists they will sponsor in any given year?
When can you apply? Do you have to be licensed first? Can you apply during your residency or only after it’s completed?
Is there more than one way to obtain a J1 waiver for that state? For example, some states (such as Alabama), have regions that fall under the designation of the ARC, DRA, and VA, as well as the Conrad 30. Having all of these options for sponsorship might increase your odds of obtaining a waiver.
How experienced is the state in processing J Waiver applications? A quick phone call to the state health department might help you to determine whether they are accustomed to handling waiver applications or whether the state is ill-informed about the proper procedures.
Below are links to individual state websites, which will help you with your research. In addition to state websites, there are some other valuable online resources that can help you find the best state. For instance, 3rnet (http://www.3rnet.org) provides up to date information on how many waiver openings are available in several states. Although this information might not be directly useful if you will be applying during a later fiscal year, it can still give you a sense of the level of competition in certain states.

Conrad 30 Web Sites:
Alabama - http://www.adph.org/OPCRH/
Alaska - http://www.chems.alaska.gov/PCRH/workforce_search_ak_exp.htm
Arizona - http://www.azdhs.gov/hsd/visa_waiver.htm
Arkansas - http://www.healthyarkansas.com/
California - http://www.prh.dhs.ca.gov/Programs/CalSORH/J1Visa.htm
Colorado - http://www.cdphe.state.co.us/pp/primarycare/J1.html
Connecticut (PDF) - http://www.dph.state.ct.us/Licensure/apps/j1info.pdf
Delaware - http://www.dhss.delaware.gov/dhss/main/sp.htm
District of Columbia - http://doh.dc.gov/doh/site/default.asp
Florida - http://www.doh.state.fl.us/workforce/recruit1/J1lforms.html
Georgia - http://gain.mercer.edu/rhic/employ.html
Guam - http://www.cehn.org/cehn/resourceguide/gdphss.html
Hawaii - http://www.state.hi.us/doh/rural-health/j1visa.htm
Idaho - http://www.healthandwelfare.idaho.gov
Illinois - http://www.idph.state.il.us/about/rural_health/rural_shortage.htm
Indiana - http://www.in.gov/isdh/publications/llo/waivers.htm
Iowa - http://www.idph.state.ia.us/
Kansas - http://www.kdheks.gov/olrh/j-1visa_waiver.html
Kentucky - http://chfs.ky.gov/#Section2
Louisiana - http://www.dhh.state.la.us/offices/?ID=88
Maine (DOC) - ftp://ftp.state.me.us/pub/sos/cec/rcn/apa/10/144/144c513.doc
Maryland - http://www.fha.state.md.us/orhpcs/pco/html/mdj1visawaiverprog.html
Massachusetts - http://www.mass.gov/dph/dphhome.htm
Michigan - http://www.mimom.org/page.cfm/41/
Minnesota - http://www.health.state.mn.us/divs/chs/j1main.htm
Mississippi - http://www.health.ms.gov/index.htm
Missouri - http://www.dhss.mo.gov/j1visa/
Montana - http://www.dphhs.mt.gov/PHSD/Primary-Care/primary-care-j-1info.shtml
Nebraska - http://www.hhs.state.ne.us/orh/j1.htm
Nevada (PDF) - http://health2k.state.nv.us/primary/JP-1.pdf
New Hampshire - http://www.dhhs.nh.gov/DHHS/RHPC/default.htm
New Jersey - http://www.state.nj.us/health/j-1/
New Mexico - http://www.nmhr.org/nmj1.html
New York - http://www.health.state.ny.us/nysdoh/dpprd/j-1a.htm
North Carolina - http://www.ncruralhealth.org/j1.html
North Dakota - http://www.med.und.nodak.edu/depts/rural/rhw/j1/
Ohio - http://www.odh.ohio.gov/odhPrograms/chss/visa/visa1.aspx
Oklahoma - http://www.health.state.ok.us/
Oregon - http://oregon.gov/DHS/ph/hsp/conrad/index.shtml
Pennsylvania - http://www.dsf.health.state.pa.us/health/cwp/view.asp?a=169&q=204585
Rhode Island - http://www.healthri.org/hsr/professions/visa/j1visa.php
South Carolina - http://www.scdhec.net/
South Dakota - http://www.state.sd.us/doh/rural/J1waiver.htm
Tennessee - http://www2.state.tn.us/health/rural/j1visa0.html
Texas - http://www.dshs.state.tx.us/chpr/j1info.shtm
Utah - http://health.utah.gov/primarycare/employment.html
Vermont - http://www.healthyvermonters.info/hi/ruralhealth/ruralhome.shtml
Virginia - http://www.vdh.state.va.us/primcare/center/j1/info.asp
Washington - http://www.doh.wa.gov/hsqa/ocrh/r&r/j1.htm
West Virginia - http://www.wvochs.org/dr/j-1.aspx
Wisconsin - http://dhfs.wisconsin.gov/localhealth/J_1VISA/
Wyoming - http://wdh.state.wy.us/main/index.asp


STEP FOUR: HIRE AN IMMIGRATION ATTORNEY

Given the confusing nature of the J Waiver process, a good immigration attorney is virtually a necessity. Once you have determined the state you want to work in, contact an attorney in that state. He/she can ensure that no stone goes unturned, and help clarify confusing aspects of the application process. The attorney can also work with your prospective employer to make sure they comply with various regulations.

Do some research to find an attorney who is up to date on recent developments affecting the J Waiver process. You also want an attorney who demonstrates that he/she is truly committed to helping you remain in the U.S.

Once you’ve hired an attorney, your work isn’t done. Not only will you need to aggressively pursue your job search, you will need to be proactive in making sure that you are involved in the application process. While an attorney should always have your best interests at heart, occasionally immigration attorneys become overwhelmed and some of their clients may fall through the cracks.

In one case, a J-1 Visa physician obtained a contract with an approved healthcare facility in a HPSA, only to find that there were no more waivers available in her state for that year. This could have been avoided if her attorney had been paying closer attention to her case.

STEP FIVE: BEGIN YOUR JOB SEARCH

Once you have found the state(s) that best matches your needs, it’s time begin looking for a J-1 Visa Waiver position. Thanks to your research, you should know whether you will be required to find employment in an MUA (medically underserved area), HPSA (health professional shortage area), or MUP (medically underserved population) in your state.

By searching online or calling the state health department, you should be able to pinpoint the counties or areas in your state that have the appropriate designation (see HPSA/MUA section above for links to websites).

From there, you can begin seeking out health care facilities in those areas. If you do not have the time to research health care facilities on your own, a service such as The Doctor Job can locate hiring contacts for you. Since The Doctor Job has the ability to search for contacts by zip code, they will be able to find all prospective employers within a designated MUA, HPSA, or MUP.

Contacting Prospective Employers

Since the J Waiver process is such a complicated one, the best thing you can do to increase your chances of success is provide prospective employers with detailed information about what it means to hire a J Waiver candidate. Many employers who might truly benefit from hiring a J-1 visa physician may shy away from the process simply because it is confusing. By convincing them that you are an expert on the J-1 waiver process, you will alleviate many of their concerns.

When contacting prospective employers, you should make it clear that you are a J-1 visa holder and that you are looking to fulfill a need in a medically underserved area. You should also indicate that you have a full understanding of the procedures needed to obtain a J Waiver, and that you would be happy to explain these procedures in an interview setting.

In a typical job search, the physician candidate is focused on meeting the needs of a prospective employer. While this is still true in a J-1 Visa holder’s job search, it is equally important that your prospective employer meet a number of criteria. The website of the IGA or state you will be applying to should have this criteria clearly listed. At the time you write to prospective employers, you might consider including a printout of these requirements along with your CV and cover letter. This way, employers will have an understanding of what will be required of them prior to contacting you for an interview. As a result, you can spend your interview discussing the ways in which you can help the practice, rather than discussing the logistics of the waiver application process.

While this again will vary from state to state and agency to agency, here are some of the most common criteria that your employer must meet:
If the employer decides to hire you, you both must a sign contract for no less than three years indicating that you will be working 40 hours a week.
The employer must practice in a geographic area or areas designated by the Secretary of Health and Human Services as a Health Professional Shortage Area (HPSA) or Medically Underserved Area (MUA) (depending on specific agency requirements).
The health care facility must accept Medicaid/Medicare eligible patients, as well as medically indigent patients.
The health care facility must describe concerted recruitment/retention efforts for an American physician. It must be clearly demonstrated that a non-visa physician could not be found.
The health care facility must commit that it will not facilitate the process of acquiring permanent residence for the physician until he/she has been employed in accordance with these requirements for at least two years.
The health care facility must employ a discounted/sliding fee schedule and provide a copy of their public notice of the availability of this discounted/sliding fee schedule.
Note: Because the health care facility has to have attempted to hire an American physician before they can hire an FMG, it’s possible that a practice may not be able to offer you a contract right away, but would potentially be interested in hiring you after their period of recruitment for an American physician has passed. For this reason, it is a good idea to approach practices as soon as possible. A service like The Doctor Job can allow you to make contact with many employers simultaneously to ensure that you find a J-1 waiver job as easily as possible.
When You Receive an Interview

If you did not include information about J-1 waiver regulations with your initial submission of a CV and cover letter, you should make sure to print out this information and take it with you to your interview. Plan on giving this to prospective employers so that they can see whether or not their facility is eligible, and gain an understanding of what they will need to do on their end if they decide to hire you. If you have hired an attorney, let the employer know that you will have assistance in completing the J-1 waiver application.

Again, showing that you are an expert in the J1 waiver process will show prospective employers that you have done your homework, and it will make you a more attractive candidate. In addition, it will prevent a situation where an offer is given and then rescinded later when the employer finds out what is involved with the J-1 visa and waiver process.

Beyond waiver issues, make sure you really sell yourself in the interview! Although the waiver process is tricky, at the root of the process is the fact that there are many underserved health care facilities in the U.S. that are in desperate need of quality physicians. Do not be afraid to talk about your strengths and convince prospective employers of the value you can bring to their practice and to the surrounding community.

Verifying HPSA or MUA Status

Once you have received an offer from a health care facility, you should call this telephone number at The U.S. Department of Health & Human Services to verify where the particular healthcare facility has received MUA or HPSA designation.

1-888-275-4772. Press option 1, then option 2 or contact the Shortage Designation Branch.

Please note that even when a website indicates an area is medically underserved, you should verify the criteria closely before accepting a position there. Since the information is only updated every few years for the purpose of disseminating it publicly, it’s possible that a location’s status has changed since it was posted online.

TIMELINE:

The timeline of your job search can be a tricky one. Normally when someone applies for a job, he/she begins working within a few weeks to a few months after accepting the offer. In the case of J Waiver candidates, however, it might be a year or more from the time you interview for a position to the time you actually begin working.

The time frame to obtain a J waiver usually ranges from six to nine months, from the first contact with the Primary Care Office until final approval from the BCIS. But also factored into this timeline is the fact that you may have to wait until you’ve fully completed your residency and obtained your license before applying.

In addition, physicians must agree to commence employment within ninety (90) days of approval of the waiver. Thus, the filing of the application should be timed with this requirement in mind. Make sure you don’t apply so early that you are still completing your residency or fellowship training at the time you are supposed to begin working.

Since the timeline will vary for each individual FMG, you should sit down with your attorney or advisor to determine the best time apply. Also, make sure you have realistic expectations regarding the timeline, and that you are able to financially support yourself during any period where you may not be working.

The Doctor Job normally recommends that you begin searching for a J-1 waiver position around 12-20 months before you plan on starting work.

WHAT A WAIVER WILL COST YOU

The estimated cost for applying for a J-1 Waiver, including attorney’s fees is between 00 and 00. In most states the application fee (approx. 00) will be wholly or partially refunded in the event that the waiver is not approved. The DRA, however, charges a 00 application fee, which is nonrefundable.

AFTER GETTING APPROVED

Once you’ve successfully obtained a waiver (congratulations!), your employer must submit an H-1B petition with the INS. The petition must be accompanied by various documents, including a Labor Condition Application accepted by the Labor Department. Upon approval of both the J waiver and the H-1B petition, you will be allowed to remain and practice in the United States following the completion of your three-year MUA/HPSA commitment.

MATCHES CAN BE MADE!

While the process of obtaining a J Waiver can be harrowing, remember that this can also be a fulfilling experience for both the physician and the employer. There are many areas in the U.S. that are in desperate need of good physicians. Unfortunately, government bureaucracy makes the match between a needy facility and a good FMG hard to make at times. But with persistence and diligence, these stories can have happy endings.

Call The Doctor Job at 1-800-591-4842 or visit us online at http://www.TheDoctorJob.com to get free career advice on finding a J-1 Waiver position. We specialize in helping J-1 Waiver physicians find jobs with employers who will NOT under-pay you or take advantage of you!


About the Author: The Doctor Job is comprised of former recruiters and career counselors with many years of experience working with professionals and physicians to help them find excellent jobs. If you are a resident, fellow, physician, or medical student looking for advice, you can get free career advice online at http://www.TheDoctorJob.com, or by calling 1-800-591-4842.




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