Chapter 7 - Health

ALERT: This policy guidance applies to all applicants and petitioners as of February 24, 2020. (The Supreme Court of the United States stayed the last nationwide injunction of the Inadmissibility on Public Charge Grounds Final Rule on January 27, 2020 and stayed the statewide injunction in Illinois on February 21, 2020.) Certain classes of aliens are exempt from the public charge ground of inadmissibility (such as refugees, asylees, certain VAWA self-petitioners, U petitioners, and T applicants) and therefore, are not subject to the final rule. For more information about the classes of aliens who are exempt from the Final Rule, click here.

Officers must consider an applicant’s health when determining whether an alien is more likely than not to become a public charge at any time in the future.[1] The applicant’s health may adversely affect an applicant’s ability and capacity to obtain and retain employment and adequate health care necessary for self-sufficiency.[2]

A. Standard

The officer assesses whether the applicant’s health makes him or her more or less likely to become a public charge at any time in the future.

When making this assessment, the officer evaluates the medical evidence provided in the Report of Medical Examination and Vaccination Record (Form I-693) completed by a civil surgeon, the medical examination report in the U.S. Department of State (DOS) Form DS-2054 or Form DS-7794 completed by a panel physician, or any other information provided by a licensed medical professional. USCIS generally defers to the report from the civil surgeon or panel physician, absent evidence that such report is incomplete.[3] The officer may also consider any additional documentation provided by the applicant relevant to the applicant’s health and any medical conditions.[4] In general, the absence of major health problems is a positive factor.

Civil surgeons[5] and panel physicians[6] are directed in the regulations governing the medical examination to determine whether the applicant has a Class A or Class B medical condition.[7] Class A conditions generally render an alien inadmissible on the health-related grounds of inadmissibility.[8]

Class B conditions generally do not render an alien inadmissible on health-related grounds of inadmissibility, but may be considered for other grounds of inadmissibility, including public charge.[9] Class B conditions are those that represent a departure from normal health or well-being that is significant enough to possibly interfere with the person’s ability to provide and care for him or herself, to attend school, or to work, or that may require extensive medical treatment or institutionalization in the future.[10]

Civil surgeons and panel physicians should ordinarily provide an explanation of a medical condition, whether Class A or Class B, that details the nature and the extent of the medical condition or the abnormality, the degree to which the alien is incapable of normal physical activity, and the extent to which the condition is remediable.[11] The explanation should also include the likelihood that, because of the condition, the applicant will require extensive medical care or institutionalization or that it may interfere with the person’s ability to provide and care for him or herself, to attend school, or to work.[12]

An officer must not attempt to diagnose or determine whether an applicant has a certain medical condition; these decisions must be made by a panel physician or civil surgeon. Further, officers must not make medical determinations as to whether the medical condition will require extensive medical care or institutionalization, or that it may interfere with the person’s ability to provide and care for him or herself, to attend school, or to work.

All determinations as to the applicant’s health must be based on the Form I-693, Form DS-2054, or Form DS-7794, or other medical or additional documentation prepared by a physician or licensed medical professional submitted by the applicant. An officer may issue a Request for Evidence (RFE) if he or she has questions about the applicant’s medical condition or its effect on the applicant’s ability to provide and care for him or herself, to attend school, or to work.

When assessing how the applicant’s health affects his or her likelihood of becoming a public charge at any time in the future, the officer should consider all factors relevant to the applicant’s case based on the medical reports and other documentation submitted by the applicant including, but not limited to:

  • Whether the applicant is in good health;

  • Whether the applicant has been diagnosed with a physical or mental medical condition;

  • The nature and severity of the condition(s);

  • Whether the medical condition is likely to require extensive medical treatment or institutionalization in the future;

  • Whether the condition affects the applicant’s capability for normal physical activity and ability to complete daily tasks;

  • Whether the medical condition will interfere with the applicant’s ability to provide and care for him or herself, to attend school, or to work; and

  • Any information relating to the prognosis of the applicant, including information on past or current medication, prospect of recovery, or extent to which a condition is progressively detrimental to the applicant’s health and mental state.

Officers must rely on the medical information, prepared by a panel physician, civil surgeon or other qualified medical professional, in making these determinations. Officers must not speculate as to the cost of medical conditions or future diagnoses. 

Having a Class A or Class B condition that is likely to require extensive medical treatment or institutionalization, or that will interfere with the alien’s ability to provide and care for him or herself, to attend school, or to work upon a grant of adjustment of status is considered a negative factor in the totality of the circumstances. The absence of a Class A or B condition that likely to require extensive medical treatment or institutionalization or that will interfere with the alien’s ability to provide and care for him or herself, to attend school, or to work is a positive factor in the totality of the circumstances.

The applicant’s health alone or the mere presence of a medical condition that is likely to require extensive medical treatment or institutionalization, or that will interfere with the applicant’s ability to provide and care for him or herself, to attend school, or to work, alone, is not outcome determinative. This includes a diagnosis by a medical professional, including a civil surgeon or panel physician, that an applicant has a disability. Although such a diagnosis is a negative factor if it prevents the alien from working, going to school, or otherwise providing or caring for him or herself, as with any other negative factor, a disability that impacts the applicant’s ability to provide and care for him or herself, to attend school, or to work must not be the sole basis for an inadmissibility determination.

The officer must always assess inadmissibility on the public charge ground in the totality of the circumstances.

B. Summary of Health

Applicant's Health

Positive Factor

Negative Factor

No diagnosed medical issues

Form I-693 (DOS medical examination report or any other medical documentation) lists a Class A medical condition[13] or a Class B medical condition[14] that the civil surgeon, panel physician, or other medical professional indicates is significant enough to interfere with the applicant’s ability to provide and care for him or herself, to attend school, or to work, or that is likely to require extensive medical treatment or institutionalization in the future.

C. Evidence

1. Immigration Medical Examination Reports

The officer must consider the applicant’s Report of Medical Examination and Vaccination Record (Form I-693) or the applicable DOS medical examination report (Form DS-2054, or Form DS-7794) submitted in connection with a visa application, or any other medical documentation submitted by the applicant. For purposes of the public charge ground of inadmissibility, an officer should generally defer to the immigration medical examination of a civil surgeon or panel physician, unless there is evidence in the record that the report is incomplete or there are other concerns affecting the quality or integrity of the report.

If the report is incomplete or if the officer has additional questions, the officer should address the deficiency in accordance with current guidance on the issuance of RFEs and Notices of Intent to Deny (NOIDs).[15]

When addressing the deficiency through an RFE or a NOID, the officer should include language directing the civil surgeon to address the medical condition and diagnosis, as well as the possible effects on the applicant’s ability to provide and care for him or herself, to attend school, or to work, or whether the condition requires any extensive medical treatment or institutionalization in the future so that the officer has sufficient information to make a public charge determination.

2. Additional Documentation

The applicant may submit, and USCIS may consider, any additional medical records, medical or mental health documentation, evaluations by licensed medical professionals, or other related documentation regarding or related to the applicant’s health and condition.[16] This documentation may include information on how the applicant’s health makes him or her more or less likely to become a public charge at any time in the future, or a clarification about a medical condition diagnosed as part of the applicant’s medical examination, or other information.[17]

Example

An applicant seeking adjustment of status submits a Form I-693 that reveals that he or she has severe emphysema, a Class B condition. The civil surgeon indicated that this chronic condition would continue to require medical treatment and might interfere with the applicant’s ability to work. However, the applicant provides additional documentation with his or her adjustment application demonstrating that he or she works in an occupation that is not physically demanding, and where his or her medical condition would not interfere with his or her ability to work.

The applicant also provides evidence from his or her employer documenting his or her gainful employment. Finally, the applicant provides medical documentation from the treating physician documenting the current treatment for the condition and that it does not interfere with his or her ability to work.

Absent other negative factors, an officer may conclude, based on these documents, and considered in the totality of the circumstances, that the applicant is not likely at any time to become a public charge in the future. Although the applicant has a medical condition that the civil surgeon indicated might affect his or her ability to work (a negative factor), the applicant has established through current employment and additional evidence that she is in fact working without issue, in the present and foreseeable future (a positive factor outweighing the negative factor).[18]

Footnotes


1. [^] See INA 212(a)(4). See 8 CFR 212.22(b)(2).

2. [^] Also, the Board of Immigration Appeals (BIA), the Attorney General, and legacy Immigration and Naturalization Service (INS) have considered a physical and mental condition to be of major significance to the public charge determination, generally in relation to the ability to earn a living. See, for example, Matter of Martinez-Lopez (PDF), 10 I&N Dec. 409, 421–23 (A.G. 1964). See Matter of A- (PDF), 19 I&N Dec. 867, 869 (Comm. 1988) (citing Matter of Harutunian (PDF), 14 I&N Dec. 583 (Reg. Comm. 1974). See Matter of Vindman (PDF), 16 I&N Dec. 131 (Reg. Comm. 1977). See 83 FR 51114, 51181-84 (PDF) (Oct. 10, 2018) (proposed rule).

3. [^] See 8 CFR 212.22(b)(2)(ii).

4. [^] See 8 CFR 212.22(b)(2)(ii).

5. [^] Civil surgeons are USCIS-designated physicians who conduct the immigration medical examination of aliens present in the United States and seeking an immigration benefit in the United States, such as adjustment of status. The civil surgeon must complete the Form I-693 according to the U.S. Department of Health and Human Services (HHS) Centers for Disease Control and Prevention (CDC)’s regulations and Technical Instructions for the Medical Examination of Aliens (TIs) applicable to civil surgeons. For more information on civil surgeons and health-related grounds of inadmissibility, see Part B, Health-Related Grounds of Inadmissibility [8 USCIS-PM B] and Part C, Civil Surgeon Designation and Revocation [8 USCIS-PM C].

6. [^] Panel physicians are DOS-designated physicians who conduct the immigration medical examinations of aliens who are abroad and seeking an immigration benefit with DOS. The panel physician must complete the DOS medical examination form according to CDC’s regulations and TIs applicable to panel physicians.

7. [^] For more information, see Part B, Health-Related Grounds of Inadmissibility [8 USCIS-PM B].

8. [^] See INA 212(a)(1). See 42 CFR 34.2(c).

9. [^] See 42 CFR 34.2(e).

10. [^] See 42 CFR 34.2(d). See CDC, Required Evaluations - Other Physical or Mental Abnormality, Disease, or Disability, Technical Instructions For Medical Examination Of Aliens. See Report of Medical Examination and Vaccination Record (Form I-693).

11. [^] See 42 CFR 34.3. See 42 CFR 34.4.

12. [^] See 42 CFR 34.4(b)(2) (Class A). See 42 CFR 34.4(c)(2) (Class B).

13. [^] See 42 CFR 34.2(d).

14. [^] See 42 CFR 34.2(e).

15. [^] For more information on addressing deficiencies or conflicting information on Form I-693, see Part B, Health-Related Grounds of Inadmissibility, Chapter 5, Review of Overall Findings [8 USCIS-PM B.5].

16. [^] See 8 CFR 212.22(b)(2)(ii).

17. [^] If the Form I-693 reveals a Class A medical condition, and the additional documentation shows that the medical condition has since been cured but is not annotated on the medical examination report, the officer may ask the applicant to obtain an updated Form I-693. Without an updated Form I-693, the officer would have to find the applicant inadmissible on health related grounds. While the additional medical documentation may be used for the public charge inadmissibility determination, an officer must rely on the information contained in the Form I-693 for purposes of an inadmissibility determination based on health-related grounds of inadmissibility. See Part B, Health-Related Ground of Inadmissibility [8 USCIS-PM B].

18. [^] For purposes of finding an applicant inadmissible on health-related grounds, the USCIS officer must only consider the information contained in the panel physician’s or civil surgeon’s immigration medical examination report. For purposes of the public charge determination, USCIS generally defers to the report, but the officer may consider additional medical documentation. For more information on health-related grounds of inadmissibility, see Part B, Health-Related Ground of Inadmissibility [8 USCIS-PM B].

10 U.S.C. 504(b) - Citizenship or residency

15 U.S.C. 1681 - Congressional findings and statement of purpose

21 U.S.C. 802 - Definitions

21 U.S.C. 841 - Prohibited acts A

22 CFR 40.51 - Labor certification

29 CFR 570 - Child labor regulations, orders and statements of interpretation

29 U.S.C. 213(c) - Child labor requirements

31 U.S.C. 9304-9308 - Sureties and surety bonds

31 U.S.C. 9305 - Authority and revocation of authority of surety corporations

38 U.S.C 1965 - Definitions

42 CFR 34.4 - Medical notifications

42 U.S.C. 1382c - Definitions

42 U.S.C. 413 - Quarter and quarter of coverage

42 U.S.C. 416(l) - Retirement age

7 CFR 273 - Certification of eligible households

8 CFR 1.2 - Definitions

8 CFR 1.3 - Lawfully present aliens for purposes of applying for Social Security benefits

8 CFR 1003.14 - Jurisdiction and commencement of proceedings

8 CFR 1003.1 - Organization, jurisdiction, and powers of the Board of Immigration Appeals

8 CFR 103.6 - Surety bonds

8 CFR 204.5 - Petitions for employment-based immigrants

8 CFR 212.20-212.23 - Applicability of public charge inadmissibility; Definitions; Public charge determination; Exemptions and waivers for the public charge ground of inadmissibility

8 CFR 212.21(b) - Public Benefits

8 CFR 212.4 - Applications for the exercise of discretion under section 212(d)(1) and 212(d)(3)

8 CFR 213.1 - Admission under bond or cash deposit

8 CFR 213a - Affidavits of support on behalf of immigrants

8 CFR 214.2 - Special requirements for admission, extension, and maintenance of status

8 CFR 214.2 - Special requirements for admission, extension, and maintenance of status

8 CFR 235 - Inspection of persons applying for admission

8 CFR 245.11 - Adjustment of aliens in S nonimmigrant classification

8 CFR 292 - Representation and appearances

8 CFR 293.1 - Computation of interest

8 U.S.C. 1363 - Deposit of and interest on cash received to secure immigration bonds

8 U.S.C. 1601-1646 - Restricting welfare and public benefits for aliens

8 U.S.C. 1611 - Aliens who are not qualified aliens ineligible for Federal public benefits

8 U.S.C. 1612 - Limited eligibility of qualified aliens for certain Federal programs

8 U.S.C. 1613 - Five-year limited eligibility of qualified aliens for Federal means-tested public benefit

8 U.S.C. 1641 - Definitions

INA 101 - Definitions

INA 101(a)(15) - Nonimmigrant classifications

INA 201 - Worldwide level of immigration

INA 203 - Allocation of immigrant visas

INA 208 - Asylum

INA 212(a)(4) - Public charge

INA 212(d) - Temporary admission of nonimmigrants

INA 213 - Admission of certain aliens on giving bond or undertaking; return upon permanent departure

INA 235 - Inspection by immigration officers; expedited removal of inadmissible arriving aliens; referral for hearing

INA 237(a)(5) - Public charge (deportable aliens)

INA 239, 8 CFR 239 - Initiation of removal proceedings

INA 245(j) - Adjustment to permanent resident status

INA 2488 CFR 248 - Change of nonimmigrant classification

INA 289 - Application to American Indians born in Canada

Inadmissibility on Public Charge Grounds, 84 FR 41292 (Aug. 14, 2019) (Final rule)

Pub. L. 104-193 - Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996

Pub. L. 104-208 - Illegal Immigration Reform and Immigrant Responsibility Act of 1996

Pub. L. 106-395 - Child Citizenship Act of 2000

Pub. L. 111-293 - Help Haitian Adoptees Immediately to Integrate Act of 2010

Pub. L. 111-8 - Section 602(b), Title VI of the Afghan Allies Protection Act of 2009

Pub. L. 113-4 - 127 Stat 54 of the Violence Against Women Reauthorization Act of 2013

Pub. L. 89-732 - Cuban Refugees Adjustment of Status

Section 11, 26 Stat 1084 of the Immigration Act of 1891

Section 212(a)(15), 66 Stat 163, 183 of the Immigration and Nationality Act of 1952

Sections 1-2, 22 Stat 214 of the Immigration Act of 1882

Appendices

Applicability of INA 212(a)(4) to Employment-Based Adjustment of Status Applications

Appendix: Applicability of INA 212(a)(4) to Employment-Based Adjustment of Status Applications

Appendix: Applicability of INA 212(a)(4) to Employment-Based Adjustment of Status Applications

Applicability of INA 212(a)(4) to Family-Based Adjustment of Status Applications

Appendix: Applicability of INA 212(a)(4) to Family-Based Adjustment of Status Applications

Appendix: Applicability of INA 212(a)(4) to Family-Based Adjustment of Status Applications

Applicability of INA 212(a)(4) to Other Applicants

Appendix: Applicability of INA 212(a)(4) to Other Applicants

Appendix: Applicability of INA 212(a)(4) to Other Applicants

Applicability of INA 212(a)(4) to Refugee, Asylee, and Parolee Adjustment of Status Applications

Appendix: Applicability of INA 212(a)(4) to Refugee, Asylee, and Parolee Adjustment of Status Applications

Appendix: Applicability of INA 212(a)(4) to Refugee, Asylee, and Parolee Adjustment of Status Applications

Applicability of INA 212(a)(4) to Special Immigrant Adjustment of Status Applications

Appendix: Applicability of INA 212(a)(4) to Special Immigrant Adjustment of Status Applications

Appendix: Applicability of INA 212(a)(4) to Special Immigrant Adjustment of Status Applications

Eligibility for Public Benefits

Appendix: Eligibility for Public Benefits

Appendix: Eligibility for Public Benefits

Totality of the Circumstances Framework

Appendix: Totality of the Circumstances Framework

Appendix: Totality of the Circumstances Framework

Technical Update - Moving the Adjudicator’s Field Manual Content into the USCIS Policy Manual

May 21, 2020

U.S. Citizenship and Immigration Services (USCIS) is updating and incorporating relevant Adjudicator’s Field Manual (AFM) content into the USCIS Policy Manual. As that process is ongoing, USCIS has moved any remaining AFM content to its corresponding USCIS Policy Manual Part, in PDF format, until relevant AFM content has been properly incorporated into the USCIS Policy Manual. To the extent that a provision in the USCIS Policy Manual conflicts with remaining AFM content or Policy Memoranda, the updated information in the USCIS Policy Manual prevails. To find remaining AFM content, see the crosswalk between the AFM and the Policy Manual.

AFFECTED SECTIONS

 

POLICY ALERT - Implementation of Guidance on Inadmissibility on Public Charge Grounds

February 24, 2020

This update incorporates into Volumes 2, 8, and 12 policy guidance that U.S. Citizenship and Immigration Services (USCIS) announced February 5, 2020, implementing the Inadmissibility of Public Charge Grounds Final Rule. This guidance is in effect as of February 24, 2020 and applies to all applications and petitions postmarked on or after that date, including in Illinois. (On February 21, 2020, the Supreme Court of the United States stayed the last remaining injunction in the State of Illinois, allowing DHS to implement the final rule nationwide.) Certain classes of aliens are exempt from the public charge ground of inadmissibility (such as refugees, asylees, certain VAWA self-petitioners, U petitioners, and T applicants) and therefore, are not subject to the Final Rule. For more information about the classes of aliens who are exempt from the Final Rule, click here.

AFFECTED SECTIONS

 

POLICY ALERT - Public Charge Ground of Inadmissibility

February 05, 2020

U.S. Citizenship and Immigration Services (USCIS) is issuing guidance in the USCIS Policy Manual to address the final rule on the public charge ground of inadmissibility. This policy guidance is effective on February 24, 2020, and will apply to all applicants and petitioners filing applications and petitions for adjustment of status, extension of stay, and change of status, except for applicants and petitioners in the State of Illinois, whose cases will be adjudicated under prior policy, including the 1999 Interim Field Guidance and AFM Ch. 61.1. For additional information, see Public Charge Inadmissibility Determinations in Illinois. Certain classes of aliens are exempt from the public charge ground of inadmissibility (such as refugees, asylees, certain VAWA self-petitioners, U petitioners, and T applicants) and therefore, are not subject to the Inadmissibility on Public Charge Grounds final rule. For more information about the classes of aliens who are exempt from the final rule, click here.

AFFECTED SECTIONS

 

Technical Update - Replacing the Term “Foreign National”

October 08, 2019

This technical update replaces all instances of the term “foreign national” with “alien” throughout the Policy Manual as used to refer to a person who meets the definition provided in INA 101(a)(3) [“any person not a citizen or national of the United States”].

AFFECTED SECTIONS

 
Current as of

CHAPTERS

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