Washington State Proposes New Conrad 30 Rules for Physician J-1 Waiver Program

Washington State is changing its rules for sponsoring J-1 waiver physicians. I recently attended the public hearing for the proposed rules change, held in Olympia, Washington. The period for public comment is over, and the rules are under final review. According to the State, the proposed changes are likely to become effective on October 1st, with new forms coming out about a month before that.


The Washington State Department of Health (DOH) administers the J-1 Visa Waiver program for physicians and hospitals. Each state is allocated 30 slots per year under the federal Conrad State 30 and Physician Access Act. Many foreign medical graduate physicians complete residencies and fellowships in the J-1 nonimmigrant classification. For many, a condition of the classification is that they return to their country of foreign residency for two years after completing their visa term. The Conrad program allows them to waive that condition, if they agree to serve an under served population for three years in the U.S. Thus, the purpose of the program is to facilitate physician medical care for underserved populations. Think rural areas for primary care, and in limited cases, urban areas for specialists serving patients from all over.

The DOH’s stated purposes for the rules changes to WAC 246-562 are:

(1) to better align with federal requirements to increase access to care for underserved populations;

(2) simplify application and reporting requirements where possible; and

(3) better allocate the scarce resource of the program’s 30 physician sponsorships to areas most in need and with practices that do the most to increase access to care for Medicaid clients, low income individuals and other underserved populations.

Highlights of the changes:

New Sponsorship Limitations. Primary care physicians in HPSAs may submit applications starting October 1st, until the state reaches the annual federal cap. Specialists are limited to 10 sponsorships from October 1st to March 31st, with no restriction beginning April 1st. Non-designated area FLEX waivers are increased to 10 total per year, available as of January 15th in the federal fiscal year. A single employer can only have three waivers, prior to June 1st of the fiscal year, until the State reaches its annual federal cap.

Specific limitations imposed upon medical facilities for use of the program. Applicants, including integrated health care systems in a single HPSA, are limited to a.) two sponsorships per practice location; b.) one hospitalist sponsorship per hospital; c.) no more than three sponsorships total across all practice locations in the HPSA between October 1st and May 31st; d.) and no more than three FLEX spots by a an applicant for a single county.

Medically Underserved Areas are stricken in the regulations, in favor of Health Protection Shortage Areas (HPSAs).

• “Financial hardship” is clarified as family income up to two hundred percent of the annual federal poverty guidelines.

History of compliance is now a factor in physician sponsorship.

• Sponsors must show at least 15% of total patient visits are for Medicaid or other low income patients. This is up from the former 10% figure.

Recruitment requirements are changed, as sponsors no longer a need to notify public service providers in the HPSA thirty days in advance by certified mail.  Also, the call for statewide newspaper ads is stricken from the regulation.

Labor Condition Applications are no longer required. This is an improvement, as a labor condition application is required at the H-1B application stage of the process. Other prevailing wage protections remain in the regulation.

Specialists no longer have a five year commitment requirement. This requirement was two more years than the requirement under federal law.  It is a deterrent for specialists, and has led to concerns when pursuing permanent residence for physicians participating in the Conrad program.

• Status reports now required every 12 months, instead of the 6 months as before.

• Physicians have an annual survey requirement and a final survey requirement one year after they complete the program, for retention studies.

• No longer need letter residency reference letter.

• Specialist requirements are somewhat streamlined.

• Regulation includes prioritization criteria for when more when the Department receives more complete applications than number of available slots.

• Certain withdrawal of sponsorship for misconduct reasons are included.

Use of the 30 physician waiver slots varies from state to state. Some states fill their quota every year on the first day. Other states barely use their thirty slots. Washington State has used all of its slots in recent years, but usually takes half the year at least to fill the quota. Demand for these slots is increasing nationally, perhaps due to the H-1B quota problem, which forces some physicians to opt for J-1 over H-1B status when initially coming to the U.S. An increase in J-1 physicians naturally leads to a subsequent demand for more J-1 waivers, as some physicians determine they wish to stay.

Hospitals and physicians interested in seeking Conrad J-1 waivers should make plans now. We shall see, but I anticipate the slots in Washington will fill faster than in past years. These proposals include less administrative roadblocks than the former rules, and move up certain dates for specialists and FLEX applications. This year, the agency received 34 applications for 30 slots, well in advance of the end of the year.