Who is required to have a medical examination prior to immigration to the United States?
All immigrants, refugees and certain non-immigrants, including fiancées, coming to the United States must have a physical and mental examination abroad by a Panel Physician (CDC). The medical examination procedure consists of a physical examination, tuberculous screening (skin test or gamma-interferon release assay in youth/chest x-ray for individuals ≥ 15 years) for tuberculosis, and blood test for syphilis. The vaccination requirements include vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). Asylees and status adjusters are NOT required to have a medical exam PRIOR to entering the US. If in detention IN the U.S., they may receive a medical exam by civil surgeons.
Overseas Pre-Departure Medical Screening/ “Fit to Fly” Check
In the pre-resettlement context, all refugees must undergo overseas medical screening prior to entry in the United States. Medical treatment prior to this appointment is variable. Prior to the “Fit to Fly” exam for refugees resettling in the United States, refugees undergo a visa medical examination and pre-departure medical screening. At the final “Fit to Fly” screening, treatment for intestinal parasites and malaria is often provided. This exam takes place 24-48 hours prior to the refugee’s departure to the United States. The main focus of this visit is to screen for the presence of individual inadmissible communicable diseases of public health significance.
Panel physicians appointed by the Division of Global Migration and Quarantine of CDC conduct the examination. The majority of overseas medical examinations are performed by the International Organization for Migration. During the medical exam, panel physicians perform a history and physical examination. Children 2-14 will have only either a tuberculin skin test or gamma-interferon release assay to test for TB and no test for syphilis. Screening for applicants ≥ 15 years includes a test for syphilis and a chest x-ray to screen for tuberculosis.
Refugees may be administered prophylactic treatment for locally endemic diseases including:
- Soil-transmitted helminths (single-dose albendazole)
- Strongyloidiasis (2 doses of ivermectin or longer dose of albenzadole if from a Loa-Loa endemic area)
- Schistosomiasis (praziquantel)
- Malaria (artermether-lumefantrine)
As of 2016, all four treatments are conferred for refugees migrating from Sub-Saharan Africa; intestinal helminths and strongyloidiasis for refugees migrating from East Asia; and, intestinal helminths for refugees migrating from the Middle East. *Of note, CDC guidelines are subject to change. Source: CDC Refugee and Immigrant Health, 2016
Asylees are persons who meet the definition of a refugee but are already in the United States or are seeking admission at a U.S. port of entry. Therefore, aslyees do not complete the overseas medical screening prior to departure. Those who are living in the United States or are seeking admission at a US port of entry when they apply for asylum are recommended to have a domestic medical exam once they have been granted asylum status. When an asylee applies for adjustment of status, an I-693 medical examination (including vaccinations) by a civil surgeon is required. Once an asylee has been granted asylum status, their family members may follow to join them in the US, and therefore these family members would undergo the required medical examination overseas, prior to immigration.
Certain non-immigrants, such as fiancées, are required to complete an overseas medical screening prior to departure. There is scant information about overseas medical screenings found for non-immigrants.
Undocumented immigrants do not undergo a medical screening prior to entry into the United States.
Domestic Medical Screening
Post-resettlement, refugees undergo a domestic medical screening which evaluates current healthcare concerns. A medical screening examination is recommended by the CDC and strongly encouraged by U.S. Office of Refugee Resettlement (ORR). ORR requires medical screenings to be conducted within 90 days of a refugee’s arrival as a condition for funding for the voluntary resettlement agency (VOLAG) that carries out resettlement for the individual. Models for domestic refugee health care delivery are dependent on funding streams specific to the refugee resettlement program in each state. This medical screening appointment takes place at a public health institution or primary care clinic.
CDC and physician-experts at Pediatric Academic Societies Culture, Ethnicity, and Healthcare Special Interest Group recommend that the physician conduct an extensive history of the patient at this time and assume that the patient has never seen a doctor. Information collected prior to this domestic medical screening exam is extremely variable, even the history collected as part of the pre-departure medical screening. The domestic screening visit is significant so that refugees start their new lives in the U.S. in good health.
Addressing immediate health concerns can be beneficial for refugees who have not had sufficient access to healthcare. Many refugees have not received routine, preventive medical care prior to arrival and this visit should be an opportunity to provide education on preventive health care. It can also help the refugee develop trust in the provider and medical system. It is an opportunity for the refugee to become familiarized with the local health care delivery system and important for establishing long term care continuity within a medical home. Finally, the screening is significant from a public health perspective as conditions might be identified that have consequences for the public such as latent TB and chronic hepatitis B virus infection.
This appointment occurs soon after arrival. It is recommended that this appointment serve as a screening for TB, mental health screening, and testing for HBV, anemia, and sexually transmitted infections. It should also confirm that the appropriate presumptive anthelminthic therapies were provided prior to departure. Recommendations for this initial domestic appointment suggest that the physician conduct a comprehensive evaluation of the following health domains using a trained interpreter:
- Immigration history
- Birth history
- Nutritional history
- Environmental exposure risks
- Treatment prior to arrival
- Prior medical records
- Family medical history
- Social history
- Educational assessment
- Substance abuse
- Sexual history
- History of trauma or abuse
- Complete Physical Exam
- Blood pressure
- Gynecological exam to evaluate presence of female genital cutting
- Complete Blood Count (CBC) with differential
- Hepatitis B
- Intestinal Tissue Invasive Parasites (ITIP)
- STDs: Syphilis | Chlamydia | Gonorrhea | HIV
Often it is difficult to cover all domains of recommended evaluation in one appointment and families may have to come back.
Currently, there are very little data available about the health problems of asylees after they migrate to the United States. Many asylum seekers originate in, or transfer through, countries with public health issues similar to those facing refugees arriving through the U.S. Refugee Admissions Program. Therefore, the CDC recommends that medical providers of asylees apply the same screening and treatment recommendations in the CDC Refugee Domestic Guidelines when performing a medical evaluation of an asylee. For individuals who have been in the United States for more than one year, special attention should be paid to diseases with long latency and associated severe morbidity such as tuberculosis, hepatitis B, and Strongyloides infection.
Domestic screening medical exams are not embedded into the path of other immigrant groups upon arrival in the United States.
If detained, undocumented immigrants undergo two medical screening. The first medical screening occurs immediately upon arrival at a facility to determine the appropriate medical, mental health, and/or dental treatment that is needed. A chest x-ray or skin test for tuberculosis is administered during this initial medical screening. Immediate attention is provided to detainees who present a danger or an imminent risk to themselves or others, such as infectious diseases, uncontrolled mental health disorders, or conditions that would deteriorate if not addressed immediately by medical personnel. In addition to the initial health care screening, they receive a health and physical examination within 14 days of arrival to identify medical conditions that require monitoring or treatment (US Department of Homeland Security, 2007).
If undocumented immigrants are not detained and become eligible for a visa, they must complete a medical screening examination as part of their visa application. This examination is performed by an authorized physician and includes screening for inadmissible conditions.
Accessing Healthcare in the United States
Following arrival to the United States, access to health insurance and health care is dependent upon immigration status, whether the individual is an adult or child, as well as federal and state level policies. Only U.S. citizens and certain lawfully presented permanent residents (green card holders) qualify for federal health insurance programs. Visitors are responsible for paying for their own medical care.
Refugees and Asylees
Following the domestic medical screening appointment, refugees are eligible for public assistance to establish a medical home with a primary care clinic. While there is not a single model for domestic refugee health care to ensure ongoing care and treatment, refugees and asylees can expect to receive access to care. Refugees and asylees are eligible for Medicaid temporarily (9 months), Child Health Insurance Program (CHIP), and Affordable Care Act (ACA) subsidies. Unstable employment places the refugee at risk for loss of health insurance; however, refugees remain eligible for some public assistance based on their legal immigration status.
Immigrants are eligible for Medicaid, CHIP, and ACA subsidies. As a caveat, if the immigrant is sponsored, it is the sponsor’s income that is used to determine their eligibility for these programs.
Non-immigrants are not eligible for US health insurance or ACA subsidies.
With the exception of emergency medical care, undocumented immigrants are not eligible for federal health insurance programs.
The AAP Immigrant Child Health Toolkit establishes that undocumented immigrant children are not eligible for Medicaid, Child Health Insurance Program (CHIP) or health insurance subsidies provided through the ACA. However, the Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to pay. While EMTALA requires that hospitals offer emergency treatment to stabilize the individual, it does not mandate preventive or out-patient care. If an undocumented parent and child presents with a medical emergency, pediatricians should not hesitate to encourage treatment at a hospital’s emergency room.
If the United States Citizenship and Immigration Services (USCIS) is aware of an undocumented immigrant’s presence but was not actively pursuing his or her deportation, Permanent Residence Under Color of Law (PRUCL) status may be granted with coinciding healthcare and social security benefits. Undocumented immigrants with PRUCL may be eligible for Medicaid under certain local and state policies.
Resources and Further Reading
- Refugee health care, an essential medical guide. Annamalai, 2014 (Access restricted)
- Care of Adult Refugees with Chronic Conditions, Terasaki et al. 2015 (Access restricted)
- CDC Refugee and Immigrant Health
- American Academy of Pediatrics (AAP) Immigrant Child Health Toolkit
- AAP Trauma Toolbox for Primary Care
- Caring for Kids New to Canada
- Migration Policy Institute
- EthnoMed Toolkit for Primary Care Providers Treating Refugees
- 2020 Washington State Health Equity for Immigrants Report