No Longer a Bar, Now a Factor: Your Health and the New Public Charge Test

You are applying for a green card, and you have a serious medical condition: HIV, diabetes, a heart condition, cancer in remission, a disability. Two questions follow. Will the medical exam keep you out? And now that the public charge rules have changed, will your health count against you?

The short answer: a chronic condition like HIV is no longer a medical bar to a green card and needs no waiver, but since September 18, 2026, your health carries more weight in the public charge test, because officers now weigh it with broad discretion and alongside any means-tested benefits you receive. You should document it in your favor. HIV was removed from the list of disqualifying diseases in 2010. What replaced the old bar is quieter: USCIS has always had to consider an applicant’s health as one of the factors that decide whether he or she is “likely at any time to become a public charge” (INA § 212(a)(4)), and under the 2026 approach that factor can decide a case. A well-managed condition, private health insurance and steady work can make that factor neutral or even favorable. A condition that limits work, with no insurance behind it, can sink an application that has a perfectly good affidavit of support.

This page explains how the health factor works, using HIV as the example because its history shows the change so clearly. The same rules apply to any serious or chronic condition. For the broader rule change, including what happened to the I-864, read our analysis of the 2026 public charge rule.

Is HIV still a reason to deny a green card?

No. HIV infection is not a ground of inadmissibility, and no waiver is needed. The health grounds of inadmissibility bar a person with a “communicable disease of public health significance” (INA § 212(a)(1)(A)(i)), and the Department of Health and Human Services decides which diseases are on that list. The current list, at 42 C.F.R. § 34.2(b), covers quarantinable diseases named by Executive Order, diseases that may pose a public health emergency of international concern, gonorrhea, infectious Hansen’s disease, infectious syphilis and active tuberculosis. HIV is not on it. (The section was last amended in 2015; we read the current text on October 2, 2026.)

It used to be. Congress added HIV to the list of “dangerous contagious diseases” in July 1987, and from then on people with HIV were barred from immigrating unless they obtained a waiver. In 1993 Congress wrote HIV into the Immigration and Nationality Act itself. In July 2008, Congress struck that language (Pub. L. 110-293, § 305), which returned the decision to HHS. HHS then removed HIV from the list by a final rule published November 2, 2009, effective January 4, 2010 (74 Fed. Reg. 56547). Since that date, HIV testing is no longer part of the immigration medical exam, and a person with HIV does not need the § 212(g) health waiver on Form I-601. Our guide to immigration waivers explains which health grounds still require one.

So the question “Do I need an I-601 because I am HIV-positive?” has a clean answer: no. The question that replaced it is the one the rest of this page answers.

What does the immigration medical exam report about my health?

The Form I-693 medical exam, done by a USCIS-designated civil surgeon, reports two kinds of findings, and only one of them is a bar.

• Class A conditions make the applicant inadmissible on health grounds: a communicable disease on the § 34.2 list, missing required vaccinations, a physical or mental disorder with associated harmful behavior, or drug abuse or addiction (42 C.F.R. § 34.4(b)).
• Class B conditions are not a bar. They are physical or mental conditions serious in degree or permanent in nature, a substantial departure from normal well-being (42 C.F.R. § 34.4(c)). Put in plain terms, the USCIS Policy Manual describes a Class B condition as one serious enough that it might interfere with the person’s ability to care for himself or herself, attend school or work, or that might require extensive medical treatment or institutional care in the future (8 USCIS-PM G.5(B)(1)).

For every Class B condition, the civil surgeon must report four things: the nature and extent of the abnormality; how far it limits normal physical activity; how far it can be treated or corrected; and how likely it is that the person will need extensive medical care or institutionalization because of it (42 C.F.R. § 34.4; 8 USCIS-PM G.5(B)(1)). Remember those four items. They are the questions the public charge officer will be reading the exam to answer.

How HIV appears in the exam. The civil surgeon does not test for HIV, but you must answer the medical history questions truthfully, and a known HIV diagnosis changes one part of the exam. Under the CDC’s Technical Instructions for civil surgeons (the version dated May 15, 2024, current when we checked on October 2, 2026), an applicant 2 years of age or older with known HIV infection must have a chest x-ray and be referred to the health department for tuberculosis sputum testing (CDC, Tuberculosis Technical Instructions). That is tuberculosis screening, not an HIV finding, and it does not make HIV a bar. The Technical Instructions do not say whether a well-controlled HIV infection should be recorded as a Class B condition; that is the civil surgeon’s medical judgment under the general Class B standard (CDC, Other Physical or Mental Abnormality). Plan for the possibility either way.

A note on privacy, because people ask. The Policy Manual says that USCIS is generally not a covered entity under HIPAA, but it handles medical information under the Privacy Act, treats it as generally confidential and uses it primarily for immigration purposes (8 USCIS-PM G.5, n. 12). Lying on the medical history to keep a diagnosis private is never the answer; it turns a manageable factor into a misrepresentation problem, as we explain in our page on why “no” can be the wrong answer on immigration forms.

How does USCIS weigh my health in the public charge test?

Health is a factor the officer must consider. The statute lists five factors every public charge decision weighs: age; health; family status; assets, resources and financial status; and education and skills (INA § 212(a)(4)(B)(i)). That has been the law for decades. What changed on September 18, 2026 is that DHS rescinded the 2022 regulations that had narrowed the inquiry (91 Fed. Reg. 45324), and USCIS now decides the statutory question directly, in the totality of the circumstances, under guidance in its Policy Manual (USCIS alert, Aug. 18, 2026; 8 USCIS-PM G). The new approach applies to adjustment applications postmarked or electronically filed on or after September 18, 2026.

Put in plain terms, the Policy Manual’s health guidance says four things (8 USCIS-PM G.5(B)):

1. The officer does not diagnose. The officer must not make medical diagnoses and should generally defer to the civil surgeon’s I-693 (or, for some adjustment applicants such as refugees and K-visa entrants, the earlier panel physician’s report).
2. Class A is a separate problem; Class B is the public charge question. A Class B condition is not a bar, but it may matter to whether the person can work, support himself or herself, or will need extensive care.
3. The condition is weighed against everything else. The officer considers how the applicant’s health affects the other factors. Even a condition that prevents work or requires extensive care can be offset if household income, assets and resources can cover the applicant’s basic needs and medical costs, or if the applicant is covered by “a health insurance policy (that is not a means-tested public benefit)” sufficient for the medical costs, together with household resources.
4. The officer may look further. The officer may consider medical information from earlier applications in the applicant’s file, and USCIS may ask for more if the I-693 is incomplete.

The Policy Manual’s own examples show how this plays out. In one, a 70-year-old applicant has a sufficient I-864 from her adult son, but her exam shows a Class B condition that requires extensive care and keeps her out of the workforce, and she has no health insurance and limited savings. The officer finds her likely to become a public charge, despite the sufficient affidavit, because nothing in the record shows how her medical costs will be paid, given the son’s other dependents (8 USCIS-PM G.10, Scenario 4). That is the lesson of the new system in one case: the I-864 is the entry ticket, not the verdict.

And the reverse is true. In the preamble to the 2026 rule, DHS said it is required to consider health but did not propose to find anyone inadmissible solely because of a diagnosis, and gave as an example a condition that does not affect the person’s ability to work or drain his or her finances, which would not make the person likely to become a public charge (91 Fed. Reg. at 45404). A diagnosis is a fact. What it costs, who pays, and whether it stops you working are what the officer is actually weighing.

If my spouse puts me on employer health insurance, does that solve the public charge problem?

It helps a great deal, but it does not “remove” the health factor, because nothing removes a statutory factor in a totality-of-the-circumstances test. What private coverage does is answer the cost question that makes a medical condition a public charge concern in the first place. The Policy Manual names exactly this as the way to offset a serious condition: a health insurance policy that is not a means-tested public benefit, sufficient for the applicant’s medical costs, considered together with the household’s income and resources (8 USCIS-PM G.5(B)(1)).

Three practical points about that coverage:

• It must be in place, not promised. Show the enrollment, the plan document or summary of benefits, and premium payments. Marriage generally opens a short special-enrollment window on an employer plan; ask the plan administrator for the deadline as soon as you marry, because missing it can mean waiting for the next open enrollment.
• It should actually cover the condition. For HIV, that means the antiretroviral medications and specialist care. A summary of benefits showing prescription coverage, and the out-of-pocket maximum, speaks directly to the officer’s cost question.
• It works with the other factors. Coverage plus the applicant’s own work history, education or job prospects is a far stronger record than coverage alone. Insurance answers “who pays”; employment answers “can this person support himself or herself.”

Do not confuse this with the affidavit of support. The I-864 is still required in most family cases, and a sufficient one is still necessary. It is simply no longer the end of the inquiry, which is why the health record has to be built separately.

Will Medicaid or HIV drug assistance count against me after September 18, 2026?

For benefits you receive on or after September 18, 2026, assume yes. USCIS will now consider “any and all” means-tested public benefits received on or after that date (USCIS alert, Aug. 18, 2026). There is no statutory or regulatory definition of a means-tested public benefit; the Policy Manual treats a benefit as means-tested when eligibility depends on income or assets below a threshold, and as public when government provides or funds it, and it lists “government-funded health coverage” among its examples. Earned benefits such as Social Security and Medicare are not means-tested (8 USCIS-PM G.2(B)).

• Medicaid is income-tested and government-funded. It counts if received on or after September 18, 2026. Receipt before that date is judged under the old, narrow rule, which looked only at cash assistance and long-term institutional care at government expense. The Policy Manual’s own example treats emergency Medicaid received in 2025 as not considered for that reason alone (8 USCIS-PM G.10, Scenario 8).
• The Ryan White HIV/AIDS Program and its AIDS Drug Assistance Program (ADAP) are not named anywhere in the Policy Manual’s public charge chapters (we searched all thirteen on October 2, 2026). ADAP is federally funded, and each state sets financial eligibility for low-income people with HIV (HRSA, Part B: ADAP). That fits the Policy Manual’s definition, so our working assumption is that ADAP enrollment received on or after September 18, 2026 can be considered. Whether sliding-fee clinic care funded by other Ryan White parts counts as “receipt” by the patient has not been addressed by USCIS. We would plan for it to be asked about. ADAP programs can also pay premiums for private or marketplace insurance; if yours does, that premium help is itself ADAP assistance, so a plan paid for that way is not the same as coverage you or a spouse’s employer pays for.
• Premium tax credits for marketplace insurance are income-based. DHS said in the 2026 rule that officers may consider means-tested tax credits received or applied for on or after September 18, 2026, while noting that many are available to middle-income families and may not indicate a lack of self-sufficiency (91 Fed. Reg. at 45400-01). Marketplace coverage bought without the credit raises no benefit question at all.

The point most people miss: continuing enrollment. If you were approved before September 18, 2026 for a benefit that runs past that date, USCIS will consider the application, approval and receipt that occur on or after September 18 unless you show that you disenrolled, withdrew the application or told the agency you no longer wanted the benefit (8 USCIS-PM G.7; 91 Fed. Reg. at 45344-45). A Medicaid or ADAP enrollment from last spring is not frozen in the past.

What this does not mean: do not stop treatment. DHS itself wrote that the rule “in no way restricts access to medical treatment” and does not change anyone’s eligibility for benefits (91 Fed. Reg. at 45362). For a person with HIV, an uninterrupted record of care and a suppressed viral load is the best health evidence there is. A gap in treatment is worse for your health and worse for your case. The right move is a planned transition: non-means-tested coverage in place first (an employer plan, the spouse’s plan, or marketplace coverage without the credit), and only then a change in public enrollment, made with your doctor and a lawyer and documented. Benefits received by family members, such as U.S.-citizen children, are not attributed to you, though household finances are still part of the picture (8 USCIS-PM G.2(C)). Do not disenroll a child from coverage he or she lawfully receives without advice.

And answer every benefit question on the forms accurately. An omitted benefit that USCIS later finds is a far bigger problem than the benefit.

What should I document about my health, and should I include a letter from my doctor?

Build the record around the officer’s actual questions: can this person work, who pays for the care, and is the condition controlled? For most applicants with a chronic condition, that means:

• Insurance. Proof of non-means-tested coverage that covers the condition: enrollment, summary of benefits, premiums paid.
• Work and capacity. Pay records, an employer letter, or a job offer; for an applicant who cannot yet work, the education, licenses and skills that show earning capacity.
• Household resources. Income and assets beyond the I-864 minimum, especially savings that could absorb out-of-pocket medical costs.
• Treatment stability. For HIV, the fact of steady treatment and viral suppression; for diabetes, controlled levels and no hospitalizations; for cancer, remission and the follow-up schedule.

A letter from the treating physician is a judgment call, not a default exhibit. Our approach: if the I-693 records no Class B condition, the health factor will usually be neutral, and attaching a detailed medical narrative the officer did not ask for can raise questions the file did not otherwise present. If the I-693 does record a Class B condition, or the condition is one the officer will plainly see in the file, a short letter is valuable, and it should answer the same four questions the civil surgeon must address: what the condition is and how extensive; whether it limits normal activity or work; whether it is treatable and controlled; and whether extensive care or institutionalization is likely. A well-controlled HIV infection, treated daily and with an undetectable viral load, answers all four in the applicant’s favor. That is the letter worth writing.

The same documentation discipline that the 2026 discretion guidance demands applies here: document, do not assert. Our page on building the record for a pending green card shows what that looks like for the rest of the file.

Does the same rule apply to diabetes, cancer, a disability or a mental health condition?

Yes. Nothing in the health factor is specific to HIV. Any condition that may affect the ability to work or may require extensive care is weighed the same way, against insurance, resources, work and skills. A young applicant with well-managed type 1 diabetes, insurance and a job presents very differently from one with the same diagnosis, no coverage and repeated hospitalizations, though the diagnosis is identical.

Disability. The Policy Manual says the health factor may include disabilities as defined in Section 504 of the Rehabilitation Act; that a disability alone is not a sufficient basis for a public charge finding; and that officers should not presume a disability means poor health or likely dependence, and should not presume it hurts the other factors, but should consider it in the totality of the circumstances (8 USCIS-PM G.5(B)(2)). DHS declined to restate that prohibition in regulation because it said Section 504 (29 U.S.C. § 794(a)) already binds it (91 Fed. Reg. at 45404). Section 504 uses the ADA’s definition of disability, and the EEOC’s ADA regulations list HIV infection, diabetes and cancer among the impairments that should easily be found to substantially limit a major life activity (29 C.F.R. § 1630.2(j)(3)(iii)). For other conditions the answer depends on their effects. Where it applies, raise it.

Mental health. Apart from drug abuse or addiction, which is its own Class A ground, a mental health condition is a Class A ground only when it comes with associated harmful behavior. Otherwise it is evaluated, like any other condition, as a possible Class B finding and a public charge factor.

Later, at naturalization. Public charge is a green card question. Once you are a permanent resident, a disability matters differently, for example as the basis for an exception to the English and civics tests; see our guide to the N-648 medical disability exception.

Who does not have to worry about the public charge test at all?

Several groups are exempt from public charge inadmissibility, so the health factor never reaches them. The Policy Manual’s list includes refugees and asylees adjusting status, VAWA self-petitioners, T and U nonimmigrants and applicants, special immigrant juveniles, applicants for registry and TPS applicants, among others (8 USCIS-PM G.3). If you are an asylee, see our guide to the asylee green card. Being exempt from public charge does not exempt you from the health grounds: most exempt adjustment applicants, such as asylees, VAWA self-petitioners and special immigrant juveniles, still need some or all of the I-693 exam, and Class A conditions still apply to them, though registry applicants need no medical exam and TPS applicants are examined only if an officer asks (8 USCIS-PM B.3).

Applicants abroad face the same statute through the State Department, where a panel physician’s report plays the role of the I-693. This page focuses on adjustment of status with USCIS; for the consular route, start with our guide to consular processing.

Is this rule final, or could it still change?

As of October 2, 2026, the rescission is in effect. Three lawsuits challenging the rule, two of which also challenge the USCIS guidance itself, are pending in the U.S. District Court for the Southern District of New York, brought by a coalition of states, by cities and counties, and by New York organizations. We found no injunction or stay as of that date. The Policy Manual guidance can also be revised by USCIS without a new regulation. Treat everything on this page about benefits and the weight of the I-864 as current as of that date, and check before you file. What will not change with the litigation is the statute: health has been a mandatory public charge factor for decades, and the documentation described above is good practice under any version of the rules.

What should I do before filing?

1. Get the medical exam before you assemble the filing and read it, so you know whether a Class B condition is recorded. The civil surgeon seals the original for USCIS, but the form instructions direct the surgeon to give you a copy; get it and read it. The I-693 stays valid for two years from the surgeon’s signature, so plan the timing around your filing date.
2. Put non-means-tested insurance in place that covers your condition, and keep proof of enrollment and premiums.
3. Map your benefit history before and after September 18, 2026, including any enrollment that continues past that date. Plan any change with your doctor, never by stopping care.
4. Assemble the work, education and household-resource record, not just the I-864.
5. Decide on the physician’s letter once you have seen the I-693, not before.

Our adjustment of status guide and our marriage-based green card guide cover the rest of the filing. A serious diagnosis is not the end of a green card case, and under the new test it is often a factor you can turn neutral with the right record. If you want to plan yours before you file, contact our office for a consultation.