According to the Federation of State Medical Boards, many states are enacting legislature that allows qualifying internationally trained physicians (ITPs) (FMGs) (IMGs) to be granted licensure without US or Canadian postgraduate training. Here are the details:
• These twelve (12) states have enacted legislation that allows qualifying internationally-trained physicians (ITPs) to gain full licensure without accredited (North American) PGT:
AR, FL, IA, ID, IL, IN, LA, MA, OK, TN, VA, and WI
• These twenty-two (22) states have pending or proposed similar legislation in the recent past (exclusive of those that have enacted legislation and introduced new legislation):
AZ, CT, GA, KS, KY, ME, MD, MI, MN, MO, NC, ND, NV, NY, OR, PA, RI, SC, TX, VT, WA, and WY
• At least three (3) states have pathways to gain limited licensure without any additional postgraduate training: CA, NY, and WA
• To see the status of these bills, please see the FSMBs “Additional Licensure Pathways Legislative Tracker”
Check back here often for updates. Many state are still pending legislature.
Arkansas State Medical Board – Revises foreign medical graduate (FMG) laws in the state, requiring the FMG’s medical school be approved by ECFMG instead of the Board (ASMB) and creates a pathway to licensure for FMGs without foreign or domestic (ACGME-accredited) PGT (as prescribed by Ark. Code § 17- 95-403(b)(3)(iii)(b)) for applicants that have: been offered full-time employment as a physician from an Arkansas healthcare provider, defined as an entity “licensed or certified to provide healthcare services by the ASMB” in an underserved or health professional shortage area; an active, unencumbered license to practice medicine in a foreign country; actively practiced medicine during the four year period preceding their application; credentials evaluated by the ECFMG; ECFMG certification; and “pass the exam used by the ECFMG” (USMLE Steps 1 & 2 and the Occupational English Test (OET) Medicine).Applicants must appear personally in front of the ASMB with their licensed, sponsoring physician, provide “information as to what area or department in which [they] will be practicing medicine.” The provisional license is valid for one year, and licensees that wish to continue must complete renewal forms and pay a fee, and may be requested to appear in person before the ASMB again. Licensees must maintain remain employed by a qualified employer for at least three consecutive years, and notify the Board within five business days after any change of employer. After two years of practice under the provisional license, the licensee is eligible for a full, unrestricted license (but must continue to practice at the qualified employer for at least one more year). Notably, Board rulemaking authority is not mentioned in the legislation.The original bill required two years of provisional practice at a qualified employer, the amended version requires three (but the licensee may acquire a full license after the first two years). The amended version includes more details about the process of granting and renewing a provisional license and explicitly states that licensees are eligible for full licensure after two years. SB 601 (2025)
Medical Board of California – The Physicians from Mexico Pilot Program (MPP) grants a time-limited IMG license to Mexican doctors licensed, certified (by entities listed), and in good standing in their specialty in Mexico that have a passing score on a specialty board review course (equivalent to that needed by U.S. applicants), have specialty specific requirements, completed a six month orientation distance learning program, completed ESL classes, and have a U.S. Social Security card (valid to work only) or Individual Taxpayer Identification Number (ITIN). Physicians enroll in a six-month externship program with a nonprofit community health center approved by the Board. MPP licenses are valid for three years and nonrenewable. The program is capped at 30 Mexican physicians that must complete 25 CE credits per year and 75 total. AB 1045 (2002)
Florida Board of Medicine – Qualifying IMGs must have an active, unencumbered license to practice medicine in a foreign country, have actively practiced medicine the entire four-year period preceding their application, completed a “residency or substantially similar postgraduate medical training” that is “substantially similar to a residency program accredited by the ACGME,” had their credentials evaluated by the ECFMG, have an ECFMG certification, and passed ECFMG examinations (USMLE Steps 1 & 2 and Occupational English Test, Medicine (OET). IMGs must have an offer for full-time employment as a physician from a health care provider in the state, must maintain their employment for at least two consecutive years in accordance with rules adopted by the Board, and must notify the Board within five business days of any change of employer. The Board may, at its discretion, “exclude foreign medical school[s] from consideration as an institution[s] that provide medical education that is reasonably comparable” to that of U.S. institutions. Legislation implies that after the two-year probationary period at a designated health care provider, the license converts to full. SB 7016 (2024)
Idaho State Board of Medicine – Effective January 1, 2025, allows international physicians that have matriculated through an international medical program, defined as any “medical education or training outside of the U.S. or Canada that is substantially similar” to the training required for physicians in Idaho and has been certified by ECFMG” to apply for the licensure pathway, so long as they are not a legal resident of the U.S. or Canada, completed a residency or PGT, practiced medicine for at least three years post PGT or completed at least 500 hours of clinical experience, are in good standing, and practiced within the last five years prior to application, possess basic fluency in English (passed OET), and have an offer of employment from a sponsoring entity, defined as health systems, hospitals, freestanding emergency departments, independent physician practices, primary care clinics, and urgent care clinics. Qualifying international physicians are granted three-year, provisional licenses so long as they obtain federal immigration status and pass USMLE Steps 1 and 2. An applicant that fails to pass either step on two separate occasions “may be required to be interviewed, evaluated, or examined by the Board.” The applicant must submit to a background test and notify the Board of any changes in employment, and must work with a sponsoring entity for the duration of the provisional license. Provisional licenses convert to full licenses after three years of practice, so long as they are not under investigation, are given a letter of recommendation from their supervising physician, and passed USMLE Step 3. H 542 (2024)
Medical Licensing Board of Indiana – Authorizes the Board to issue a limited license to an ITP that pays a $100 application fee; has a medical doctorate or substantially similar degree from an international medical program in good standing as determined by the Board; has ECFMG certification; is in good standing with the medical licensing or regulatory institution in their country of practice and has no pending discipline; completed a residency, clinical training, or PGT “substantially similar, as determined by the Board” to those ACGME-accredited; has practiced medicine or osteopathic medicine for at least five years of the last six years preceding application; passed all Steps of the USMLE; has Federal immigration status; is proficient in English; and has a written offer of employment at a health care facility, defined as a hospital, birthing center, or “other medical facility,” in an underserved area, which are designated by the Dept. of Health; and that facility both agrees to sponsor and supervise the provisional licensee. Limited licensees must practice at qualifying health care facilities defined above, may not practice “outside the scope of specialty of the onsite board-certified supervising physician,” patients must be informed that they are being seen by a limited licensee, and the licensee’s prescriptive abilities are limited, must be supervised, delineated in a written practice agreement, and a statement from the facility’s governing body granting the licensee practicing privileges. The limited license must be renewed biennially and is valid for six years. After a minimum of five years, the limited license may be converted to full at the discretion of the Board. The Board is empowered to require a comprehensive evaluation to assess the licensee’s competency prior to issuing a full license, and also may revoke the limited license if the licensee ceases practicing at a qualifying facility, or there is another “compelling reason” to do so. The bill is effective July 1, 2025, and sunsets December 31, 2040. Unrelated to additional pathways, the bill also requires applicants for osteopathic licensure to complete COMLEX within 10 years of passing COMLEX Level 1. The original bill did not have a limitation on time out of practice, required only USMLE Steps 1 & 2 for provisional license, explicitly stated that ITPs needed five years of practice experience post-PGT, and did not have the sponsor and supervise portion of the employment offer. The second revision added an application fee, gave the Board the ability to assess the similarity/quality of foreign PGT, provided more guidance regarding the limited licensee’s supervision and scope, and empowers the Board to utilize a comprehensive assessment prior to issuing a full license. • Final amended version gives the Board discretion to determine international medical programs that meet its standard for limited license applicants, requires the offer of employment to be written, further details the limited licensees circumscribed practice, and adds a decade to the sunset date of the bill. HB 1555 (2025)
Illinois Department of Financial and Professional Regulation – Effective January 1, 2025, “shell bill” authorizes the Dept. of Financial and Professional Regulation (IDFPR) to issue limited licenses to qualified IMGs, pursuant to rules the IDFPR must adopt regarding qualifications and fees. According to the Illinois State Medical Society, IMGs “would work for two years with limited practice under supervision in an area with medical need or with a health professional who treats underserved populations.” Relatedly, HB 2948 (2023) creates a new ombudsman position within IDFPR to help eligible IMGs navigate the relicensing process. SB 1298 (2023) On January 14, 2025, the IDFPR promulgated rules to implement SB 1298. The rules define IMGs as: Medical graduates trained outside the U.S. whose education has “been certified by the ECFMG;” having passed all steps of the USMLE; having an unencumbered license from another country; and not licensed to practice medicine in the U.S. IMGs are eligible to apply for a limited license to practice medicine in the state, and the IDFPR, upon its determination of fitness, may issue the license, which is valid for two years. Applicants must: Submit an application, plus $100 fee; provide an official transcript and diploma; provide their ECFMG certificate (waivable if the applicant hails from a “non-cooperating country”); have practiced in at least three of the last 10 years, and if the applicant has not practiced within the last three years, they must show evidence of U.S. clinical experience; submit to a background check; and enter into an agreement with a sponsoring entity, defined as a hospital, critical access teaching hospital, FQHC, state facility, CHC, or another facility approved by the IDFPR; that “provides an assessment and evaluation program designed to develop, assess, and evaluate the physician’s nonclinical and clinical skills and familiarity with standards appropriate for medical practice.” Limited licensees may only practice within the sponsoring entity and under the supervision of a “faculty supervisor” that is a fully licensed physician, and must file a practice agreement between themselves and the sponsoring entity with the IDFPR. The sponsoring entity maintains professional responsibility for the licensee, the licensee must notify the IDFPR if the practice agreement is terminated. The limited license may be renewed every two years, in accordance with Ill. Admin. Code tit. 68 § 1285.120, with an exception to the CME requirements in the initial licensure period. After at least two years of practice under the limited license, licensees may apply for a restricted license, which entitles licensees to practice independently in health professional shortage areas (HPSAs) as defined by the IDFPR. Applicants for the restricted license must: Successfully complete the two-year supervised work experience at the sponsoring entity, including the assessment and evaluation program; show proof of “anticipated” employment in an HPSA; and pay a $230 fee. After at least two years of restricted practice (at least four years total), the licensee is eligible to apply for a full, unrestricted medical license. IDFPR Rules (see § 1285.345)
Iowa Board of Medicine – Effective January 1, 2025, allows the Board to grant provisional licenses to IMGs that are graduates of foreign medical schools evaluated by the ECFMG, licensed and in good standing for the immediately preceding five years, without pending disciplinary action; have completed a residency or “substantially similar” PGT in their resident country, have practiced medicine for at least five years following their PGT, possess basic English fluency and Federal immigration status, have an offer of employment at an Iowa health care facility; and have passed the USMLE (which steps not explicitly mentioned). The provisional license may be converted to a full license after three years of practice in good standing and without violation of Iowa Stat. § 148.6, as long as the licensee was employed by the health care facility for the entirety of the three-year period and passes a background check, among other administrative components. SF 477 (2023)
Louisiana State Board of Medical Examiners – Effective August 1, 2024, allows the Board to issue licenses to IMGs that hold a degree from an international medical program that is “substantially similar” to the education or training required to practice in the state, are licensed in good standing with the regulatory body in their home country, have completed a residency or similar PGT in their licensing country, or have at least five years’ experience as a practicing physician, have U.S. or Canadian citizenship or legal work status in the U.S., as well as English proficiency, and have an offer of employment at a facility owned or operated by state-licensed hospitals. Licensees must practice at these licensed facilities for the first two years of their licensure but “after such time the licensee is no longer subject to this limitation,” and the Board can revoke the license with “clear and convincing evidence” that services rendered violated medical safety, competency, or conduct standards established by the Board. The Board shall promulgate any necessary rules and regulations to enforce the legislation. HB 972 (2024)
Massachusetts Board of Registration in Medicine – Creates a limited license for internationally-trained physician (ITP) that have an ECFMG certificate, unless granted an exemption by the board; passed USMLE Steps 1 and 2; received a degree of doctor of medicine or its equivalent from a legally chartered medical school recognized by the WHO; been licensed and practiced medicine for at least one year; and entered into an agreement with a participating healthcare facility, defined as a federally qualified health center (FQHC), community health center (CHC), hospital or other healthcare facility approved by the board that will “develop, assess and evaluate the applicant’s familiarity with nonclinical skills and standards appropriate for medical practice in the Commonwealth” according to criteria developed or approved by the Board. The Board may require additional criteria to limited practice. The limited license is valid for one year, with one possible renewal. ITPs that pass USMLE Step 3, their facility’s assessment, and any additional requirements may apply for a once-renewable, two-year restricted license to practice medicine only in a physician shortage area. However, any additional eligibility prerequisites “shall not include post-graduate clinical training” and the restricted licensee may practice independently in a primary care specialty, psychiatry or other specialty as approved by the board. After at least two years (three to six years overall) of restricted practice, the ITP may apply for a full, unrestricted license to practice medicine. H 5100 (2024)
North Carolina Medical Board – Original bill would have permitted the Board to issue an “internationally-trained hospital physician employee” license to IMGs FMGs that possess an active license in good standing from a foreign country or had such a license that expired within the last five years, practiced medicine for a minimum of five years, completed 130 weeks of medical education at a school in the World Directory of Medical Schools (WDOMS), eligible for ECFMG certification, completed two years of PGT at a World Federation for Medical Education (WFME) accredited program or practiced medicine for at least 10 years, passed a medical licensing exam or received board specialty certification or submitted to a comprehensive assessment approved by the Board; never had a license revoked, suspended, restricted, or otherwise acted against in any jurisdiction and not subject to pending investigations, nor have any convictions regarding “moral turpitude,” felonies, or involving the practice of medicine, be proficient in English and have legal authorization to work in the U.S. Applicants must be offered employment at an accredited hospital or at a rural practice supervised by a physician licensed in the state, with rules for supervision promulgated by the Board; These licensees are prohibited from practicing medicine or surgery outside the confines of the North Carolina hospital or its affiliates, and the license becomes inactive if the physician chooses to do so within the ambiguous provisional license phase. Conversion to full licensure (unbound by practice limitations) is not mentioned. HB 125 (2023)
New York Office of the Professions, Medicine – New York law provides that the Board can grant limited permits for qualifying IMGs that:• “Fulfill all requirements for a physician license except those relating to the examination and citizenship or permanent residence in the U.S.”; are ECFMG certified or “passed an examination satisfactory to the Board;” and have a non-immigration visa for the continuation of medical study. Permittees are authorized to practice medicine under the supervision of a licensed physician and only in a public, voluntary, or proprietary hospital. Limited permits are valid for two years and may be renewed for up to two additional years if NYSED’s Office of the Professions receives written evidence of progress toward licensure and justifying cause for renewal. Limited permits may not be extended beyond four years of practice. Applicants for a limited permit must meet the same educational requirements as those applying for licensure. NY Educ L § 6525, NYSED License Requirements (Limited Permits), 8 NYCRR Part 60.6
Oklahoma State Board of Medical Licensure and Supervision – Makes the ECFMG the arbiter of whether a foreign applicant for full licensure, using the “traditional licensure pathway” (when an ECFMG-certified IMG matriculates through accredited GME prior to licensure), graduated from a satisfactory international medical program. Applicants must meet all requirements in 59 OK Stat § 493.2, including 12-24 months of GME. Regarding additional licensure pathways, the bill authorizes the Board to issue limited licenses to qualifying IMGs that: graduated from a medical school which meets ECFMG requirements; pay an application fee; complete a three-year PGT program in the licensing country or practiced medicine for at least three of the last five years outside of the U.S.; has English proficiency, determined by the ECFMG; and has an offer of employment as a physician at a health care provider in the state that operates an ACGME-accredited PGT program. The limited licensee must provide care at a qualifying facility, supervised by the chair of the department within the applicant’s intended practice. After three years of limited practice, the Board may grant a full license, so long as the limited licensee is in good standing without disciplinary actions or investigations pending and has passed all steps of the USMLE. HB 2050 (2025)
Tennessee Board of Medical Examiners – SB 1451: Effective July 1, 2024, allows the Board to issue a temporary license to IMGs that have demonstrated competency as “determined by the Board,” completed a three-year post-graduate training program in their licensing country; or has otherwise practiced as a physician for at least three of the last five years outside the U.S., and an offer for employment as a physician at a healthcare provider in the state with an ACGME-accredited PGT program. Temporary licensees may only practice at qualifying healthcare facilities. After two years of practice in good standing, the Board shall grant a licensee an unrestricted license. SB 1936: Enacted May 6, 2024, but not effective until January 1, 2025, amends SB 1451 by requiring IMGs on the alternate pathway to complete three years’ of PGT in their licensing country and practice as a physician for at least three years outside of the U.S. USMLEs are required. The legislation also empowers the Board to use their discretion in licensing decisions, stating that the Board may issue a full license after two years of provisional licensure (previously, bill language was that the Board shall issue this license). SB 1451 (2023) SB 1936 (2024)
Virginia Dept. of Health Professions Board of Medicine – Effective July 1, 2024, allows the Board to grant a provisional license to a qualified IMG for up to two years, that have received a degree from a medical school recognized by the WHO, are licensed in another country and practiced medicine for at least five years, have a valid ECFMG certificate (waivable upon the Board’s discretion), passed USMLE Steps 1 and 2, has entered into an employment agreement with a medical care facility “that provides an assessment and evaluation program designed to develop, assess, and evaluate the physician’s nonclinical skills and familiarity with [state] standards “according to criteria developed or approved by the Board” and has “satisfied any other criteria that the Board may require for issuance of a provisional license.” Licensees may apply for a renewable two-year extension if they practice in a medically underserved area, achieve a passing score on USMLE Step 3, enter another full-time employment relationship with a medical facility. After at least two years of practice under the renewable license (at least four years overall), the physician may apply for a full, unrestricted license. HB 995 (2024)
Washington Medical Quality Assurance Commission – The “clinical experience” license works as a “bridge to residency” for qualifying IMGs that are a Washington state resident for at least one year, ECFMG certified, have passed all steps of the USMLE, completed a background check, have an offer from specified state agencies and maintain practice agreement with the Washington Medical Commission’s (WMC) supervising physician. Licensees may only “practice in connection with his or her duties in employment with the city or county health department.” License valid for two years, with one possible renewal (total practice time of four years). At the conclusion of the license period, IMGs must still complete a residency to achieve full licensure. According to FSMB’s International Medical Graduates GME Requirements (Key Issue Chart), Washington requires two years of accredited PGT. SHB 1129 (2021) IMG Clinical Experience License
Wisconsin Department of Safety and Professional Services – Effective July 1, 2024, allows the Board to grant provisional licenses for qualifying IMGs that have an offer for employment as a physician from a FQHC, CHC, hospital, ASC, or any other health care facility approved by the Board, a medical degree from an international medical program approved by the ECFMG or a program that is “substantially similar” to those required to qualify for a medical license in the state, completed a residency program or PGT “substantially similar” to a residency, practiced for at least five years in their home country post-PGT, and for at least one year continuously out of the previous five prior to application; are ECFMG certified, have Federal immigration status and basic English fluency, and passed all Steps of the USMLE. Provisional license holders must submit a statement to the Board every six months certifying that they are still practicing and whether they have faced any license discipline, with the condition that the license may be revoked if the licensee is no longer working for a qualifying employer. Provisional licensees must practice under supervision, but the provisional license can convert to full licensure after three consecutive years of practice in good standing. The Board is authorized to promulgate rules defining what degrees and PGT are “substantially similar” to requisite medical degrees and residency training. AB 954 (2024)
