A visa is an endorsement on a passport indicating that the holder is allowed to enter, leave, or stay for a specified period of time in a country; it does not guarantee entry into the United States. A visa allows a foreign citizen to travel to the U.S. port-of-entry, and the Department of Homeland Security U.S. Customs and Border Protection (CBP) immigration inspector authorizes or denies admission to the United States. At the port of entry, upon granting entry to the United States, the Department of Homeland Security, U.S. immigration inspector, provides you an admission stamp or paper Form I-94, Arrival/Departure Record in your passport. On this admission stamp or paper Form I-94, the U.S. immigration inspector records either a date or "D/S" (duration of status). If your admission stamp or paper Form I-94 contains a specific date, then that is the date by which you must leave the United States.
Visas are issued only at U.S. consulates outside of the United States. Visa status is the legal grouping under which the foreign national is categorized once physically present in the United States. Visa status is granted by the customs official at the U.S. port-of-entry or by the regional service center of USCIS.
International medical graduates (IMGs) represent nearly a quarter of the physician workforce in the United States. The total number of IMGs practicing in 2013 was 200,000, almost 24% of the entire workforce (Center for Workforce Studies. 2014 Physician specialty Data Book. Washington, DC; Association of American Medical Colleges; November 2014). Similarly, IMGs cover nearly a quarter of residency positions: 23.9% of residency positions in the US in 2014 were secured by IMGs (Accreditation Council for Graduate Medical Education (ACGME). Data Resource Book: Academic Year 2013-2014. Chicago, IL: ACGME; 2014). Furthermore, American Medical Association (AMA) statistics from 2017 estimate that there are 280,000 practicing IMGs in the United States, or about one in four practicing doctors.
Consequently, securing first the visa to train and, then, one to work in the country are difficult tasks, and there are many pitfalls along the way that stifle a physician’s aspirations to train and practice in the United States.
This article solely focuses on temporary nonimmigrant visa as they relate to an International Medical Graduates (IMG), such as J1 and H-1B. It doesn’t discuss the visa interview process or the immigration process after H-1B. Please contact the U.S. Citizenship and Immigration Services (USCIS) at www.uscis.gov for additional and updated details.
Common Types of Visas:
1. Immigrant Visa
An immigrant visa (also known as a green card or permanent resident status) permits a foreign citizen to permanently remain in the U.S. A lawful permanent resident (LPR) has the right to become a naturalized U.S. citizen after living in the United States for 3 to 5 years. To obtain immigrant status, one must qualify as:
- A specified immediate relative of a U.S. citizen or another LPR
- An employee of a sponsoring employer or prospective employer
- A "diversity immigrant" under a visa lottery program.
2. B1/B2 Visas
These are temporary, nonimmigrant visas. B1 is for individuals coming to the US for business purposes (work visa), the B2 for pleasure/tourism (tourist visa). The visa might be issued as “B1/B2”, meaning it encompasses both activities.
The B2 visa seems quite similar to an ESTA (Electronic System for Travel Authorization) under the Visa waiver Program, but is not the same thing. The difference between a B2 and an ESTA permit is that the latter is not a visa, granting its holder an unlimited number of trips for two years, but each visit cannot be longer than 90 days. ESTA holders do not need to make a new application before each trip.
A B1/B2 visa is a legal permit to enter the United States. They might be granted for a period of 1 to 6 consecutive months but do not authorize the holder multiple entries.
3. F1 Visa
This is a student visa. There are certain requirement that need to be met in order to obtain this visa:
- The applicant must be enrolled in an academic educational or language training program and the school must be approved by the Student and Exchange Visitors Program, Immigration & Customs Enforcement;
- The applicant must be enrolled full time;
- The applicant must be able to demonstrate that they have sufficient funds to support themselves through the duration of the school program.
The visa options for residency – J1 versus H1B
Physicians seeking to enter the United States to engage in graduate medical training can normally enter on either an H-1B or a J-1 nonimmigrant visa. The vast majority (about 90%) enter the country with J-1 exchange visitor visas in a J-1 category specifically carved out for graduate medical training.
4. J1 or “The Cultural Exchange Visitor” visa
The fundamental concept of the J visa is based on fostering global understanding through educational and cultural exchanges by the way of making the visitor return to the home country to share his or her experiences. The J-1 visa is sponsored by the Educational Commission for Foreign Medical Graduates (ECFMG). ECFMG sponsors those foreign medical graduates who have complied with the requirements pertaining to entering a U.S. residency or fellowship. One of the main issues with a J-1 visa is understanding whether or not the holder is subject to the 2-year rule (two-year home residency requirement); this requirement does not allow the visa holder to become a permanent resident or change their status to another visa until they return to the country in which the visa was requested (usually your home country) for at least two years. In this period, you are not prohibited from traveling to the United States but may not benefit from certain employment-based or family-based visas until the foreign residency requirement is satisfied. While the methods for determining who is exempt for this rule are beyond the scope of this article, an exception to the 2-year rule applies to those physicians who come to the U.S. for observation, consultation, teaching, or research in which there is little or no patient care. The alternative to the two-year rule is obtaining a waiver of the two year foreign residency requirement.
Most IMGs enter on the J-1 visa because that is what they are told they need by their training programs. But that is largely because administratively, programs find it easier to bring physicians over on J-1 visas, since the heavy lifting is done by the ECFMG, the sole sponsor of all J-1 physicians in clinical training (for more information, visit https://www.ecfmg.org/evsp/application-process.html)
To apply for a J-1 visa, an IMG must meet the following criteria:
- Have a valid ECFMG Certificate.
- Have a contract or official letter of offer for a position in a program of Graduate Medical Education.
- Provide a statement of need from the Ministry of Health of the country of last legal permanent residence (LPR) regardless of country of citizenship.
Obtaining the J1 Visa
To apply for a J-1 visa, you will need a Form DS-2019, “Certificate of Eligibility,” issued by the ECFMG. This document is sent to the Training Program Liaison (TPL) at your host institution after all necessary application materials have been received, reviewed, and approved. The TPL will, in turn, forward Form DS-2019 to you. Once you obtain a Form DS-2019 from your Sponsor, you may apply for an exchange visitor J-1 visa at the nearest U.S. embassy or consulate in your country of residence.
The documents needed for the application include but are not limited to
- Form DS-2019 (Certificate of Eligibility) issued by your sponsor program
- Other supporting documents – check the specific embassy or consulate website
- Passport valid for travel to the United States
- Completed Online Form DS-160, nonimmigrant visa application
- Fee receipt showing payment of the $140 visa application fee ( may change )
- 2×2 photograph, meeting format requirements
A consular officer will interview you to determine your qualifications for an exchange visitor visa, and may request additional documents, such as evidence of:
- The purpose of your travel
- Your intent to depart the United States after your travel
- Your ability to pay all travel costs
Evidence of your employment and/or your family ties may be sufficient to show the purpose of your travel and your intent to return to your home country. If you cannot cover all the costs for your travel, you may show evidence that another person will cover some or all costs for your travel.
Exchange visitors beginning new programs may not enter the United States more than 30 days before their program start date.
Visa expiration during J1
If your visa has expired and you do not plan to travel outside of the US, you do not need to renew the visa.
If your visa expires and your DS-2019 is still valid, you can travel to Canada, Mexico and the Caribbean for a maximum of 30 days without an updated Visa stamp.
Please be aware that if you travel outside of the United States during your current exchange visitor program and after your J-1 visa has expired, you must apply for a new J-1 visa in any country outside the US in order to re-enter the United States to continue your program. This part can be difficult as you may get delayed in reprocessing or get stuck in the process if your embassy doesn’t deem your reapplication strong enough. If your visa goes into administrative processing, by the official website, it will be processed within 60 days. Your sponsor (ECFMG) is responsible for assisting and advising you as well as authorizing your travel each time you go outside the US and you will have to go through the whole application process each time, although in some situations, you may be able to bypass the interview when renewing the visa (the dropbox system).
Switching training specialties on J1
The regulations governing the Exchange Visitor Program state that “…the alien physician may once, and not later than two years after the date the ‘alien physician’ enters the U.S. as an Exchange Visitor (or acquires exchange visitor status), change his/her designated program of graduate medical education or training.
Moonlighting on J1
A J-1 holder is only allowed to perform the activity listed on his/her Form DS-2019 and as stated in the regulations for that category of exchange. The J1 visa is only an educational and cultural exchange visa, meaning its not a “work visa”. J1 physicians cannot work outside of the engagements mentioned on the DS-2019. However, if the activity falls under the scope of the residency program and is done at the same hospital site, additional compensation may be obtained.
Health insurance on J1
All J-1 exchange visitors and accompanying J-2 dependents secure comprehensive health insurance effective on the program start date indicated on Form DS-2019 and maintain coverage, without interruption, for the full duration of stay in the United States. Most ACGME-accredited residencies and fellowships provide health insurance options as a benefit of the training program. It is each J-1 physician’s responsibility, however, to ensure that the offered plan(s) meet(s) J-1 regulatory insurance requirements, which are as follows:
- Medical benefits of at least $100,000 per accident or illness
- Deductible that does not exceed $500 per accident or illness
- Co-insurance paid by J-1 not to exceed 25% of covered benefits per accident or illness
- Minimum repatriation of remains in the amount of $25,000
- Minimum medical evacuation expenses in the amount of $50,000
Taxes on J1
Any foreign national present in the United States for any part of the calendar year must file a “tax return” with the Internal Revenue Service (IRS) by the following April (the actual date varies each year). J-1 exchange visitors and J-2 dependents must file tax returns regardless of whether they earned income while in the United States. For tax filing purposes, foreign nationals are considered either Non-resident Aliens or Resident Aliens.
Extending the J1
Any IMG seeking to extend his/her participation in ECFMG-sponsored training beyond seven years must file a formal extension request with the DOS through the ECFMG. The following documentation is the minimum required to file such a request:
- Complete Application for ECFMG Sponsorship
- Letters of Support from Applicant’s Current and Proposed Program Directors.
- Statement of Educational Objectives (SEO) from the Applicant. The SEO must detail the benefits of the proposed training and anticipated professional activities upon return to the home country.
- Letter of “Exceptional Need” signed by either the home country’s Ambassador to the United States or the home country’s Minister of Health confirming an “exceptional need” for the applicant to be trained in the field of medicine being pursued
- ECFMG Application Fees of $525.00 and DOS Fee of $367.00.
All documentation supporting an applicant’s exceptional extension request should be forwarded to ECFMG in one package for review. After review, if deemed eligible to petition the DOS for extension, ECFMG sends it to DOS which can take upto 60 days for review and final decision. However, bear in mind that, the approval will weigh heavily on any future consideration of a request for a waiver of the two-year home country physical presence requirement of Section 212(e).
The J1 Waiver process and its alternatives
Most J-1 waiver programs require physicians to work 3 years on an H-1B visa following the waiver of the J-1 home residency requirement. To qualify for a J-1 waiver, physicians typically need to:
- Find a job in a physician shortage area
- The job needs to be with an employer that has recruited extensively for the job (with proof)
- The state has to have a waiver program with slots available or a federal program needs to be available in the area
- The employer has to be willing to go through all of the paperwork necessary to get the physician working
Physicians should begin their job search early in order to have the time to get a J-1 waiver and an H-1B visa. Ideally, they should allow at least a year to get the paperwork processed. J-1 waivers can take a long time to process and, in addition, available slots can run out quickly as the H-1B category has a quota, so physicians may find that they are stuck waiting many more months.
Waivers of the two-year foreign residency requirements to physicians can be on the basis of hardship, persecution, Interested Government Agency (IGA, a waiver by an interested U.S. Federal Government Agency showing that it is in the public interest of the United States to waive the two-year rule requirement on behalf of the physician and explaining why it would be detrimental if the physician may be returned to his home country) or a request of a waiver by a Designated State Public Health Department or its Equivalent (referred to as Conrad State 30 Program: each of the 50 States has 30 annual J-1 waiver slots to place physicians in medically underserved locations).
5. The H1B visa
An H1B is a temporary nonimmigrant visa that allows a US employers to petition and hire foreign skilled workers to work in specialty occupations. SUch visa has a duration of 3 years, extendable to a maximum of 6.
Historically, IMGs working in the U.S. on H-1B visa status believed they had the “better” of the available training visas compared to J-1 physicians and, accordingly, many physicians chose their training programs based on whether the program offered H-1B visas. However, the H-1B visa has its own challenges to consider when selecting among visas.
On October 1, 2003, the number of H-1B visas available each year dropped from nearly 200,000 to 65,000 each year. That means that many physicians will not be able to secure a visa when needed and will need to wait for a new quota to become available when a new fiscal year begins each October. Many will be fortunate enough to find a position that is exempt from the H-1B cap. University and nonprofit research institution employers are exempt from the cap, as are other nonprofit organizations affiliated with or related to a university or nonprofit research employer. From a physician’s point of view, the H-1B is usually the visa of choice if the goal is to eventually settle in the United States. The avoidance of the home residency requirement (2 year rule of a J1 visa) under INA Section 212(e) cannot be overstated for many doctors, particularly those pursuing career paths that do not easily lend themselves to a waiver strategy.
But obtaining an H-1B visa is not always easy, and even getting H-1B status is not free from problems. For example, some training programs last more than 6 years, but the H-1B visa is only available for 6 years (although a petition can be filed to extend its duration by 1 year increments). With an I-140 petition approval, the H-1B status can be extended in three year increments if the only reason an I-485 green card application cannot be filed is because of oversubscribed per country limits (persons born in India or China).
Additionally, physicians can usually enter a training program in the United States having passed just the first two USMLE steps but, to qualify for an H-1B visa, a physician must pass Step 3.