On December 29, 2025, the Department of Homeland Security (DHS) published a Final Rule in the Federal Register that fundamentally changes how U.S. Citizenship and Immigration Services (USCIS) will run the H-1B cap lottery.
For healthcare organizations that rely on the H-1B visa to recruit international nurses and other healthcare professionals, this new rule has real-world consequences for workforce planning, budgeting, and immigration strategy. At VisaMadeEZ, an immigration law firm focused on helping hospitals, long-term care facilities, and other healthcare employers hire international nurses, we are closely tracking what this means for the healthcare sector.
Below is a clear, practical breakdown of the new rule and its impact on healthcare employers and foreign-trained nurses.
What Changed in the H-1B Cap Lottery?
Under the old system, the H-1B cap selection process was essentially a random lottery. Once H-1B cap registrations were submitted, USCIS ran a computerized random selection to fill:
- The regular H-1B cap (65,000 visas), and
- The U.S. master’s cap (an additional 20,000 visas).
All eligible registrations had the same chance of being selected, regardless of the offered wage level.
The new DHS Final Rule replaces this uniform random lottery with a weighted selection system that gives an advantage to higher-paid H-1B positions based on Occupational Employment and Wage Statistics (OEWS) wage levels.
How the New Weighted H-1B Selection System Works
Instead of treating every H-1B registration equally, USCIS will now assign more “entries” or chances to registrations with higher OEWS wage levels.
The OEWS wage levels (I–IV) are commonly used when filing H-1B petitions and Labor Condition Applications (LCAs). Under the Final Rule, each wage level will be associated with a different number of “tickets” in the selection process:
- Level I (entry-level wage): 1 entry
- Level II (qualified wage): 2 entries
- Level III (experienced wage): 3 entries
- Level IV (fully competent / highly experienced wage): 4 entries
In practice, this means:
- An H-1B registration with a Level IV wage will be entered four times into the selection pool.
- A Level III registration will be entered three times, and so on.
All wage levels still participate in the H-1B cap lottery, but higher wage levels have significantly better odds of selection.
For healthcare organizations hiring international nurses, this directly ties H-1B selection chances to your wage strategy.
DHS Received Thousands of Comments – But Did Not Change the Rule
Before finalizing this policy, DHS issued a Notice of Proposed Rulemaking (NPR) in September 2025 and received nearly 17,000 public comments.
Many stakeholders including healthcare employers and industry associations urged DHS to:
- Create an exemption or special consideration for healthcare occupations, especially in rural hospitals, critical access facilities, and healthcare shortage areas; or
- Give additional weight or priority to occupations in *critical sectors*, including healthcare.
DHS ultimately declined to:
- Carve out exemptions for any particular industry, including healthcare; and
- Provide extra weight for registrations in “critical sectors,” such as nursing and other frontline healthcare roles.
Instead, DHS finalized the rule exactly as proposed, with no modifications, meaning healthcare employers must compete under the same wage-based system as all other industries.
When Does the New H-1B Rule Take Effect?
The Final Rule becomes effective on:
February 27, 2026
This timing is important for healthcare employers and international nurses planning ahead:
- The new weighted selection system will apply to the H-1B Cap Registration Season for Fiscal Year (FY) 2027.
- If you are planning to file H-1B cap registrations for international nurses or other healthcare workers for FY 2027, your wage level strategy must align with this new rule.
Impact on Healthcare Employers Hiring International Nurses
1. Wage Levels Now Directly Affect H-1B Chances
For hospitals, skilled nursing facilities, and other healthcare employers, the OEWS wage level you choose will now have a direct effect on:
- Your probability of H-1B cap selection, and
- How competitive your job offers must be to secure international nursing talent.
A Level I wage may still be technically permissible for some nursing roles, but it will carry only one entry in the lottery. In contrast, a Level III or IV wage could multiply your odds of selection.
This creates a strong incentive to:
- Reassess your wage scales for international RNs and allied health professionals;
- Consider whether it is cost-effective to offer higher wages to increase H-1B selection chances; and
- Coordinate salary decisions with HR, finance, and immigration counsel.
2. Rural and Shortage-Area Employers Face Special Challenges
Many healthcare providers in rural communities or medically underserved areas already struggle to match big-city compensation. Since DHS rejected calls to create a special exception for healthcare roles in shortage areas, these employers may find themselves:
- Offering lower relative wages (and therefore lower wage levels); and
- Facing lower odds of H-1B selection under the new weighted system.
Strategic planning is now crucial. Alternative visa categories (such as certain TN, E-3, O-1, or non-cap H-1B options where applicable) may need to be explored in parallel.
3. Budgeting and Workforce Planning Become Even More Critical
For healthcare organizations that rely on international nurses, this Final Rule adds another layer of complexity to workforce planning:
- Budget decisions around salaries now also influence immigration outcomes.
- Employers must weigh the cost of higher wages against the risk of losing out in the H-1B lottery.
- Coordination among recruitment teams, HR, legal, and finance is now more important than ever.
What This Means for International Nurses
For internationally educated nurses looking to work in the United States on an H-1B visa, this rule makes the offered wage level a key part of your immigration strategy:
- Positions classified at higher OEWS wage levels will have better chances of being selected in the cap.
- When comparing job offers, it is now important to ask:
- What wage level will the employer use on the LCA?
- How will that level affect the odds of H-1B cap selection?
International nurses should also:
- Work with experienced immigration counsel to understand whether H-1B is the best fit;
- Explore alternative options such as EB-3 immigrant visas for nurses (where applicable), or other nonimmigrant categories depending on qualifications and nationality; and
- Carefully review how their job title, duties, and salary will be classified for immigration purposes.
How VisaMadeEZ Helps Healthcare Organizations Navigate the New Rule
VisaMadeEZ is an immigration law firm that focuses on helping healthcare organizations hire international nurses and build sustainable, compliant staffing models.
In light of the new DHS Final Rule on weighted H-1B selection, we help healthcare employers:
- Evaluate wage levels: Analyze OEWS wage data for nursing and other healthcare positions, and determine realistic wage levels that balance budget constraints and H-1B selection odds.
- Develop H-1B cap strategies: Design tailored H-1B cap filing plans, including wage-level planning, timing, and risk management.
- Explore alternative visa options: Identify non–H-1B solutions where possible, including immigrant visa pathways for nurses and non–cap-subject categories when available.
- Align immigration with HR and recruitment: Coordinate with HR teams and nurse recruitment partners to ensure that compensation, job descriptions, and immigration filings work together.
For international nurses, we provide guidance on:
- Understanding the H-1B process under the new rule;
- Evaluating employer offers with an eye toward wage levels and immigration success; and
- Exploring longer-term green card options, especially for nurses in high-demand areas.
Key Takeaways for Healthcare & Nursing Immigration
- USCIS is moving from a purely random H-1B cap lottery to a weighted selection system based on OEWS wage levels.
- Higher wage levels (Level II, III, and IV) will receive more entries in the lottery, significantly improving odds of selection.
- DHS did not create any special preference or exemption for healthcare occupations, rural employers, or critical sectors.
- The Final Rule is effective February 27, 2026 and will apply starting with the FY 2027 H-1B cap registration.
- Healthcare employers and international nurses must now treat wage levels as a central part of H-1B immigration strategy.
If you are a healthcare organization planning to hire international nurses or an international nurse seeking U.S. employment VisaMadeEZ can help you navigate these new H-1B rules, structure competitive and compliant offers, and explore the best immigration pathway for your situation.
To discuss how this DHS Final Rule may affect your facility or your career, contact VisaMadeEZ for a tailored consultation.
