Webinar produced especially for foreign graduate residents, fellows, and physicians as well as medical employers and recruiters. Provides an in-depth overview of the special immigration rules and options for physicians to practice medicine in the United States. Takes the mystery out of complex immigration rules and regulations and provide you with the knowledge, tips, and tools to successfully navigate the immigration maze for physicians and medical employers.

1. Immigration Prescription for Physicians 2014
Presented by Cowles & Thompson

2. Webinar Agenda
J-1 Physicians and
Waivers
H-1B Visa Fundamentals
for Physicians
Permanent Residence
(Green Card)
Questions & Answers

3. Physician Immigration Overview

4. J-1 Physicians
After residency or fellowship training
is completed, all J-1 physicians must
return to home country for two years
or obtain a waiver of this requirement
before he or she can be employed in
H-1B status or adjust to permanent
residence (“green card”).

5. Waiver of Home Residency Rule

6. Interested Government Agency (IGA)
Conrad 30 State
Program
Department of
Veterans Affairs
(VA)
United States
Department of
Health and Human
Services (HHS)
Appalachian
Regional
Commission
(ARC)
Delta Regional
Authority (DRA)

7. J-1 Waivers – Conrad 30 State Program
• Varying deadlines and opening dates
• Evaluation process differ
• Unused slots do not rollover
• Proof of recruitment required
30 slots per fiscal year –
October 1 to September 30
• http://datawarehouse.hrsa.gov/GeoAdvisor/Shortag
eDesignationAdvisor.aspx - HPSA or MUA
designation website
• 10 FLEX slots available for non-underserved areas
Health Professional Shortage
Area (HPSA) or Medically
Underserved Area (MUA)
• Some states require four or more years
• Non-compete not allowed
• Agree to start date within 90 days of waiver
Three year minimum
contract required
• Priority usually given to primary care
• Hospitalists may be considered specialists
• Some states may restrict number of specialists slots
Primary care or specialty,
depending upon state

8. J-1 Waivers – Appalachian Regional Commission (ARC)
Covers
Appalachian
region
www.arc.gov
Three year
contract and
extensive
recruitment
required
HPSA and
primary
outpatient
care only (no
hospitalist)
$250,000
liquidated
damages
clause
required
No limit on
number of
waivers per
year

9. J-1 Waivers - U.S. Department of Health and Human Services (DHHS)
Federal agency
covers entire United
States
• http://www.globalhealth.g
ov/exchangevisitorprogr
am/index.html#waiver
Clinical care waiver
• Primary care only in HPSA
with 7 score
• Public health center, rural
health clinic, or tribal
medical facility qualifies
• Three year contract and
proof of recruitment
required
No limit on number of
waivers per year but
physician cannot have
completed residency more
than one year before waiver
start date

10. J-1 Waivers – Delta Regional Authority (DRA)
Federal agency
covering eight
state region
• http://www.dra.gov/
for list of eight states
Three year
contract required
and $250,000
liquidated
damages
required
HPSA or MUA
work location
and recruitment
required 60 days
minimum before
application
Primary care or
specialty and no
limit on number
of waiversyear

11. J-1 Waivers – Department of Veteran Affairs (VA)
Primary care
or specialty
1 year
contract
minimum but
3 years work
required by
USCIS
No limit on
number of
waivers per
year
Direct
application by
VA to
Department of
State

12. J-1 Waiver Obligations You Must Know
Physician must work in H-1B status for minimum of
three years
Physician must be a an employee, not independent
contractor, of sponsoring employer
Employer and physician must submit periodic
reports to state or federal health agency
Physician cannot change employer unless
extenuating circumstances, e.g. termination by
employer . Personal reasons usually not valid
for change of employer
Physician cannot become a permanent resident
until waiver service is completed

13. Timeline for the J-1 Waiver to H-1B Process
Employer and
Physician apply to
IGA
IGA issues
recommendation to
Department of State
(DOS) (1 to 3
months)
DOS issues
recommendation to
USCIS (1 to 2
months)
USCIS issues final
waiver approval I-612
(1 to 3 months)
H-1B petition filed
and approved (1 to 4
months)
Total time – 4 to 12
months

14. Strategic Planning for J-1 Physicians
Start job search
immediately after 2nd
year of residency or
one year before
completion of
fellowship
Target employers
located in HPSA/MUA
or FLEX locations
Sign contract by early
Fall of 3rd year of
residency or final year
of fellowship
Meet with qualified
immigration attorney

15. H-1B Physicians
IMG Physicians who
completed residency or
fellowship with H-1B visa
(no J-1)
J-1 Physicians who
returned to home country
for two years after
residency or fellowship
completed
J-1 Physicians who
obtained hardship or
persecution waiver and
seek employment

16. H-1B Physicians and the H-1B Cap
 Limit of 65,000 new H-1B visas per
fiscal year (except Free Trade Act
(FTA) nationals)
 20,000 per fiscal year for persons
who hold US Master’s degrees or
higher
 Fiscal year runs from October 1 to
September 30
 Employers may apply for H-1B on
April 1 with a start date
of October 1
 In 2014, over 170,000 new H-1B
petitions filed the first week of April

17. H-1B Numerical Limitations “H-1B Cap”
Who is subject to the cap?
– First time H-1B beneficiaries (employee)
– Beneficiaries who already hold H-1B status
but were employed by cap-exempt
employers
– Physicians who maxed out the 6 year H-1B
limit, left the U.S. for one year, and wish to
return

18. Avoiding the H-1B Cap
Cap-exempt employers
• Universities and non-profit
petitioners affiliated with
post-secondary
educational institutions
• Government research
organizations and non-
profit petitioners affiliated
with government
research institutions
• For-profit employers who
place physician at a non-
profit, university-affiliated
facility for at least 50% of
work week
Cap-exempt beneficiaries
• Physicians who are
beneficiaries of J-1 IGA
waivers only (does not
include hardship waivers
or persecution waivers)

19. Employer Obligations for H-1B
• Employer must pay minimum of prevailing wage or actual
wage, whichever is higher, for the term of the H-1B
– http://www.flcdatacenter.com/ - Department of Labor wage data for
prevailing wage
– Salary must be guaranteed at prevailing wage or actual wage –
productivity bonuses okay after minimum guarantee
– Contracts must offer same benefits and can have same requirements as
other physicians but cannot recover H-1B costs or other green card costs
• Employer must pay ACWIA fee of $750 (25 or fewer
employees) or $1500 (greater than 25 employees) unless
exempt
• Payment of attorneys fees are “safe harbor” from DOL
complaints

20. Employer Obligations for H-1B (continued)
• Physician must be on payroll within 30 to 60 days from H-1B
approval date, regardless of pending hospital privileges or
other credentialing issues
• Physician must be an employee of sponsoring employer;
however, independent contractor arrangement is possible if
physician forms corporation or LLC (self-employment)
• Employer must pay return transportation costs for physician if
employment is terminated

21. H-1B Facts to Know
• H-1B status can be valid up to 3 years initially, renewable for
3 more years. Physician is eligible for another 6 years after 1
year outside U.S.
• 6 year maximum stay with some exceptions -
– 1 year extensions available after 6th year if green card
application pending for at least one year
– 3 year extension available if green card application is on hold
because of limited availability of green cards
• If new H-1B, physician cannot work until visa is approved
• Dependent spouses (H-4) cannot work - 2014 proposed rule
may grant employment authorization to some H-4 spouses

22. Strategic Planning for H-1B Physicians
Start job search
immediately after
2nd year of
residency or one
year before
completion of
fellowship
Target cap-
exempt employers
and apply early for
medical license
Finalize
employment by
early Fall of 3rd
year of residency
or final year of
fellowship
If competing for
cap-subject
H-1B, have
contract in place
by February so
that H-1B petition
can be filed on
April 1
Meet with qualified
immigration attorney

23. Lawful Permanent Residence (Green Card)
PERM
Labor
Cert
National
Interest
Waiver
EB-1
Relative
Petition

24. PERM Labor Certification
Employer must show no
available and qualified U.S.
citizen or permanent resident
physician through local
recruitment
Employer must show ability to
pay prevailing wage
Physician must be qualified at
the time of filing of labor
certification
Physicians are EB-2 category

25. National Interest Waiver
• Two types
– General – physician’s research work is in
national interest
– Physician – 5 years medical care in HPSA or
MUA – specialties accepted
• Self-sponsored and self-employment possible
• Physicians are EB-2 category

26. EB-1A Extraordinary Ability
Basic Requirements
• Must show sustained national or
international acclaim in applicant’s field of
endeavor
• Overall evidence must show applicant has
“risen to the top of the field”
• Must show prospective contribution to the
United States
• Can be self-sponsored but must show
prospective employment in the U.S.

27. EB-1A Extraordinary Ability
Must Meet 3 of 8 Criteria
• National or internationally recognized prizes or
awards
• Membership in organizations requiring
outstanding accomplishments
• Published materials in major or professional
media about applicant’s work
• Judging the work of others, individually or on a
panel
• Original contributions of major significance to
the field

28. EB-1A Extraordinary Ability
Must Meet 3 of 8 Criteria (cont)
• Authorship of scholarly articles
• High salary or compensation as compared
to others in the field
• Performance in a leading or critical role
for distinguished organizations
• Other comparable evidence

29. Relative Sponsorship
Immediate relative
USC spouse
USC child over 21
Preference Relationship
USC or LPR parent
LPR spouse
USC brother or sister

30. Timeline
Immigrant Visa
Number must be
available . Visa
backlog delays
Physicians with
IGA J-1 waivers
cannot obtain
permanent
residence before
completion of
service
Permanent
Residence

32. Legal Notice
Facts of individual situations differ.
The information provided here is general in
nature and should not be relied upon for
specific situations.
Consult with an experienced immigration
attorney to get the right diagnosis and
prescription for your specific situation.

33. THE IMMIGRATION PRESCRIPTION
Step by step, this book will show you how
international medical graduates can legally
practice medicine in the United States. You
will learn:
 The various ways to waive the two-
year foreign residency requirement for
the J-1 visas
 The best paths to permanent residence
(green card) and citizenship
 Your responsibilities as a legal
immigrant
 How to get and maintain legal
immigration status for family members
 And more…!
For your free copy, email
mbadmus@cowlesthompson.com
For immigration updates, visit
www.physicianimmigration.com