Q&A with a J-1 Waiver Physician

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It’s no small task to navigate the U.S. immigration and visa process while simultaneously finishing your medical training. To hear first-hand insights about the J-1 waiver process, we spoke with a physician who has recently finished the job search process and signed an employment contract to qualify for a J-1 waiver.

Here are some highlights from that conversation:

To start, can you tell us a little bit about your professional background and your J-1 visa status?

Of course! I am a Family Medicine physician finishing up a Sports Medicine fellowship. I am originally from India, and I am currently on a J-1 visa. This training visa will end this summer when I graduate fellowship. Following graduation, I have signed on to begin work at a practice that qualifies for a J-1 waiver, and this employer will sponsor my H1-B visa.

What is a J-1 waiver exactly?

For physicians, a J-1 visa is a training visa usually sponsored by the Educational Commission for Foreign Medical Graduates (ECFMG). It allows international physicians to train in the United States for a maximum period of 7 years. After completing training, a J-1 physician must either return to his or her home country for two years before applying to jobs in the U.S. or secure a J-1 waiver position in the U.S.

A J-1 waiver waives the requirement for J-1 physicians to return to their home country on the condition that they work with patients in underserved communities for a minimum of three years. To be eligible for a J-1 waiver, a practice must meet very specific requirements. Once a physician’s waiver is approved, they are eligible to apply for an H1-B work visa with USCIS, and later, a green card. 

How do you know which practices qualify for J-1 waiver?

First, a qualifying practice must serve communities in which 70-80% of patients are uninsured or on Medicaid/Medicare. The practice must also have a payment plan option for uninsured patients. Finally, the employer must have advertised the position in question for at least six months before it can be offered to a non-citizen.

Typically, federally qualified health centers (FQHCs), rural health centers, academic residency or university programs under National Interest Waiver, and community hospitals in underserved areas will qualify for the J-1 waiver program. To see if a practice qualifies, you can start by checking its Health Professional Shortage Area (HPSA) score. 

How did you go about finding the right J-1 waiver position for you?

First, you have to pick which geographic location. Depending on your preferences, family situation, and specialty, your search area could span the entire country or only one specific area.  

Second, you have to choose what type of practice you want to work at, namely in-patient versus out-patient.  I chose the out-patient route and looked for an FQHC practice.

Finally, you will need to look for practices that meet the J-1 waiver requirements. I looked at sites like Indeed, 3Rnet and Practice Link.  One thing I was not prepared for: not all qualifying practices are willing to sponsor a J-1 waiver. Some practices that meet all the technical requirements for a waiver are still not interested in taking on the responsibility and cost of the sponsorship process. Hence, my advice would be to broaden your search to begin with and get multiple contracts before making a decision. 

Once you find the position, how do you go about getting a waiver?

Well, there are different pathways to getting a waiver, and it is very important for physicians to understand the deadlines for each path. 

The first opportunity is through the state Conrad 30. The Conrad 30 is a program led by each state’s Department of Health, and each year it offers 30 waivers per state to physicians who have secured contracts at an underserved practice in the state. Any speciality can apply to a Conrad 30 position, but at least half of the slots are typically reserved for primary care practices (i.e. Family Medicine, Internal Medicine and Pediatrics specialities). The Conrad 30 applications open in each state on October 1st and closes on March 31st

How competitive are waivers through the Conrad 30?

Applications are considered in the order that they are received, so it really depends on where you are applying. States like California, Texas and New York are very sought-after. My friends who applied in these states signed their contracts well in advance, immediately hired immigration attorneys, and even took the whole day off on October 1st to sit in front of their computers and submit their Conrad-30 applications the first second possible. Within half an hour, all the application slots were filled. 

By comparison, less populous states like Washington or South Dakota might still have open Conrad 30 slots as late as February or March. So, if you’re a specialist and you were not able to get a spot in one of the major states or you had a set-back with an employer, please do not panic!!

And what happens if you do not get a spot through the Conrad 30? You mentioned there were other ways to pursue a J-1 waiver.

There are, but your options depend on your specialty. For specialties like pulmonary, hematology-oncology, gastroenterology, and cardiology, the Conrad-30 is your best chance at the visa waiver. 

On the other hand, primary care specialities have another opportunity to get a waiver through the United States Department of Health and Human Services (HHS). However, while the Conrad-30 offers waivers to physicians who are working in any underserved practice, waivers through HHS require physicians to specifically work at a federally qualified health center (FQHC) or rural health center (RHC). 

Another important caveat: you must file for a waiver through HHS within one year of completion of your residency. In my case, I did a one year fellowship after graduating residency, so to adhere to the HHS waiver rules, I would have had to start my employment the exact same day that I graduate from fellowship. For me, this was not a realistic timeline, so I opted to apply through Conrad-30 rather than HHS. 

Another option is a J-1 hardship waiver, although these are rare and difficult to obtain. To receive a hardship waiver, you must prove that returning to their home country for two years would cause extreme hardship for you or your family typically due to political, social or economic conditions. An immigration attorney can help you determine if you may qualify for this waiver. 

How early should J-1 physicians begin the job search?

Once again, it depends. A physician can sign a contract as early as two years before graduation, and some employers offer stipends and loan repayment assistance for signing early. To take advantage of these opportunities, you should be deciding where you want to work, applying and interviewing 20-24 months before graduation. 

If you wanted to begin working in June 2020, you would have had to begin deciding what state(s) you wanted to work in no later than June 2019.  Then, you can spend July and August applying and interviewing, and both you and your employer will have September to prepare and submit your applications before Conrad-30 opens.

My personal timeline was a little different. I was offered a contract from an employer at a desirable location in December 2019. The next month, out of nowhere, they stopped responding to me.  Suddenly, I was back at square one. Thankfully, my state’s Conrad-30 still had openings, and since I had interviewed extensively, I was able to go with my next choice.

That must be every J-1 physician’s worst nightmare. How did that change the way you evaluated potential employers?

First, I expanded my search. I would recommend that all J-1 physicians broaden their job search, even if they think they know where they want to work. When you have 10 or 15 different potential contracts to compare, it is much easier to see what is lacking in an offer and learn what to expect.

There are also a couple red flags that I learned to watch out for. If the employer has never before sponsored a J-1 physician, I personally did not feel comfortable with that. There are horror stories of employers who have initially agreed to the sponsorship process, but then backed out when they started to understand the extent of cost and paperwork. As you may have figured, timing is everything in this process.

A second red flag is if the employer tries to reduce your compensation to offset the cost of immigration sponsorship. I even had potential employers ask me to pay for the costs, which is illegal. Not only does this sort of trivial bargaining show that they are not really invested in employing me, it also discrimination to pay someone less because of their country of birth. When you’ve worked very hard to be able to practice and serve patients, there is absolutely no reason to put up with such an attitude.

If you’re excited about a position but not the compensation package, it is perfectly appropriate to negotiate, leverage other offers, and communicate your expectations. You should never be afraid to walk away when an offer does not seem fair or reliable. There is something better waiting for you, so be patient and persistent. 

Where did you turn to for help throughout the J-1 waiver process?

Well, first I found a Facebook group specifically for J-1 health care professionals. It has provided a lot of support and tips, and there are physicians from various specialties’ and countries. This type of network can help with little inquiries like what documents you should carry when travelling internationally on a J-1/ H1B visa or how to schedule a visa interview at consulates. This group was also a huge source of encouragement and reassurance to me. It helps to realize that you are not alone during this crazy, stressful process, and there is immense support from other physicians who are in the same boat.  

Of course, many of the best answers can come from an immigration lawyer. Whenever I had issues with specific contracts or employers, I definitely relied on immigration lawyers. Usually, the employer will provide you with an immigration lawyer, but you should also do your research to verify that their lawyer has specific experience with J-1 waivers. If not, you can request to bring in your own immigration lawyer to assist with the negotiation and sponsorship process. 

Most immigration lawyers I have encountered are sensitive to these issues and understand the intricacies of the J-1 waiver process. Often, they will offer a free initial consultation, and then you can decide whether to pursue their proposed solution. 

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Frequently Asked Questions

What is a J-1 visa?

A J-1 visa is a non-immigrant visa for research scholars, professors and other professionals participating in cultural exchange programs. For physicians, J-1 visas are usually sponsored by the Educational Commission for Foreign Medical Graduates (ECFMG) to allow foreign-born physicians to complete their medical training in the United States.

Who can apply for a J-1 visa?

In order to pursue a J-1 visa for graduate medical training, a physician must pass the U.S. Medical Licensing Examination (MSLE). The physician must also have a ECFMG certificate with valid examination dates, an official offer from an approved graduate medical education or training program, as well as a Statement of Need from the Ministry of Health of their most recent country of permanent residence. To learn more, consult the Educational Commission for Foreign Medical Graduates.

What is the 2-year home residency requirement?

The terms of a J-1 visa require that J-1 physicians return to their home country for a minimum of two years after completing their training before they can apply for another visa in the United States. This is known as the two-year home country physical presence requirement. However, a physician can bypass this requirement by obtaining a J-1 waiver.

What is a J-1 waiver?

A J-1 waiver releases physicians from the J-1 visa two-year home residency requirement, provided that they work at a qualifying facility in an underserved community for at least three years.

Who can apply for a J-1 waiver?

A physician of any speciality who has secured a contract at a qualifying, underserved practice may apply for a J-1 waiver through their state’s Conrad-30 program. However, due to high need, a certain number of waiver slots are typically reserved for primary care physicians. 

While less common, any physician with a contract at qualifying underserved practice may also apply for hardship or persecution-based waiver if they or their family could face undue risk or hardship as a result of the two-year home residency requirement.

Primary care specialists who plan to work at a federally qualified health center (FQHC) or a rural health center (RHC) have an additional opportunity to apply for a waiver through the Department of Health and Human Services (HHS).

Can a J-1 visa holder work in the US?

Generally, the United States Citizenship and Immigration Services’ (USCIS) only allow J-1 holders to work for their program sponsors. This means that a J-1 physician may work as a resident or fellow as part of their training, but they cannot work as an attending physician on a J-1 visa.

How long can you stay on a J-1visa?

J-1 physicians are typically allowed to stay in the United States for up to seven years in order to complete their graduate medical education. If a physician needs to remain in the U.S. longer in order to sit for specialty board exams, it is possible to obtain an extension of J-1 status.

Can I work after my J-1 visa expires?

Not without a new visa. A J-1 visa is intended for training physicians, not working physicians. In most cases, a J-1 visa expires one month after the end of a physician’s training. At this point, if a physician has not already filed for a H1-B or alternative visa, they must return to their home country.

How do I get a J-1 waiver?

To receive a waiver, you must first sign an employment contract with a qualifying employer working with a medically underserved community. Then, your employer must submit evidence that the position meets the criteria for a J-1 waiver job. Finally the physician must apply for a J-1 waiver through an appropriate state or federal agency based on your specific speciality and circumstances. Depending on your state or speciality, there may be a highly limited number of J-1 waivers available.

How long does a J-1 waiver take?

The exact timeline varies, particularly depending on what organization you apply for your waiver through. Before you can apply for a J-1 waiver, your prospective employer must submit paperwork verifying that the position meets the qualifications for a J-1 waiver job, a process that can take about two weeks. Once you submit your J-1 waiver, it will need to be approved by both the state government and the federal government, which usually takes 6-8 weeks in total.

What happens after you get a J-1 waiver?

Once your J-1 waiver is approved, you (or your immigration lawyer) can file for an H1-B visa through USCIS. It typically takes about two weeks for an H1-B visa to process. Before your H1-B visa can be approved, you must have your practicing state license for the state in which you plan to work.

Can a J-1 visa holder apply for a green card?

No. A J-1 visa is a non-immigrant visa, and therefore J-1 visa holders are not eligible to apply for a green card. After either obtaining a J-1 waiver or fulfilling the 2-year home residency requirement, a former J-1 visa holder can apply for an H1-B employment visa. Once an H1-B visa is approved, a sponsoring employer may file for a green card on the physician’s behalf.