Chapter 6 Conrad 30 Waivers for Working in Medically Underserved Areas

• Jurisdiction: United States

In 1994, the U.S. Congress enacted legislation permitting state health agencies to sponsor up to 20 physicians each year for J-1 waivers based on their commitment to work in medically underserved communities. In the years since, every state and several U.S. territories have created Conrad J-1 waiver programs. Before 1994, only federal agencies could act as interested government agencies (IGA) in sponsoring J-1 doctors for waivers.

Congress has revisited the Conrad program from time to time. It expanded the number of waiver slots granted to each state from 20 to 30 and provided a path for states to designate up to 10 waivers per year for locations that are not actually designated as underserved but serve patients coming from underserved areas. Each state may determine its own rules for demonstrating whether underserved patients are being served, which is why these 10 waivers are called “flex slots.”

There are common requirements each state must include in its waiver requirements, but there is also considerable room for states to add additional requirements, and the programs vary considerably. This chapter reviews the common requirements for State 30 waivers and also highlights some of the additional rules imposed by the states. Appendix H provides waiver requirements and information for each state.

What are the common requirements for Conrad 30 state health agency J-1 waivers?

There are only a handful of mandated requirements for Conrad 30 (also called State 30) programs. Most of the rules each state includes in their programs are decided by the particular state. Section 214(l) of the Immigration and Nationality Act (INA) sets out the requirements for the state programs, and they include the following:

• The physician agrees to work for three years in the qualifying location;

• The physician agrees to begin work within 90 days of the waiver being granted by U.S. Citizenship and Immigration Services (USCIS);

• The physician agrees to serve in an underserved area or to serve patients residing in underserved areas;

• The offer is for full-time employment; and

• If the position is in a specialty, the employer documents the shortage of that type of specialist.

The U.S. Department of State requires state health departments to include the following items in a J-1 waiver recommendation request:

1. A completed Form DS-3035, J-1 Visa Waiver Recommendation Application;

2. A letter from the director of the state department of health identifying the international medical graduate by name, country of nationality or country of last permanent residence, date of birth, and also stating that it is in the public interest that a waiver of the two-year home residency requirement be granted;

3. An employment contract between the doctor and the health care facility named in the waiver application that includes the following:

a. The name and address of the health care facility.

b. A statement that the doctor agrees to begin employment with the employer within 90 days of receiving the waiver.

c. The specific geographical area or areas where the doctor will practice medicine.

d. A statement by the doctor that he or she agrees to meet the requirements set for in INA §214(l).

e. A term of at least three years in a designated Health and Human Services (HHS) shortage area or in an area that serves patients residing in a shortage area (a flex slot).

f. A full-time schedule (at least 40 hours per week) in the underserved area(s).

4. Proof that the location is an HHS-designated shortage area.

5. Copies of all Forms IAP-66 or DS-2019, Certificate of Eligibility for Exchange Visitor (J-1) Status.

6. A copy of the doctor’s curriculum vitae.

7. If the doctor is otherwise contractually obligated to return to the home country, a copy of the statement of no objection from the doctor’s country of nationality or last residence.

What is an HHS-designated shortage area?

Deter-mining whether an area is an HPSA, MHPSA, MUA, or MUP is not near-ly as diffi-cult as it once was. In the past, one would need to research the cen-sus tract location number and then find the Federal Register publica-tion where designa-tions were listed from time to time.

HRSA’s website, https://data.hrsa.gov/tools/shortage-area al-lows any-one to type in a facility address or county to find out whether a location is desig-nated, what the HPSA or MUA identifi-cation number is, what the loca-tion’s score is, and when the des-ignation was granted.

The U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) measures shortages of medical professionals and has created two types of areas that qualify—Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas (MUAs).

HPSAs are designated for primary care, dental, and mental health providers. In 2015, there were 6,100 designated primary care HPSAs in the United States. There were 4,000 mental health professional shortage areas. Even though the supply of specialists is not measured, J-1 waiver rules use HPSA designation as a threshold requirement for those applications. Some states use the Mental Health Professional Shortage Areas (MHPSA) designation for psychiatrists, though many will consider such doctors even if the area is only designated an HPSA.

HPSA designation is granted to a geographic area, population group, or an individual facility. If primary-care designation is granted based on a geographic area, it is because the area has a physician to population ratio of 1:3,500 or worse. A population group with access barriers making it more difficult to find care may result in an area receiving a population group HPSA designation. In those cases, the shortage ratio is lessened to 1:3,000.

For mental health areas, geographic designation is based on a ratio of 1:30,000. The threshold is lowered for population group designations to 1:20,000.

Individual facilities can receive special HPSA designation. For primary-care...