USMLE Service Transition 2026: The Complete IMG Guide

On January 12, 2026, the USMLE program completed one of the most significant administrative restructurings in its history. All IMG Step exam services (registration, scheduling, eligibility management) moved from ECFMG to FSMB. At the same time, US student Step 3 services moved from FSMB to NBME.

For International Medical Graduates, this transition created immediate confusion: Where do I register now? What happened to my ECFMG account? Does this affect my ECFMG Certification? Is my existing scheduling permit still valid?

This guide answers every question and gives you clear, actionable steps.

What Happened: The Two-Phase Transition

Phase 1 (January 12, 2026): IMG services move to FSMB

The Federation of State Medical Boards (FSMB) now manages all USMLE Step exam services for International Medical Graduates. This includes:

• New exam applications (Step 1, Step 2 CK)
• Eligibility determination for IMGs applying for Step exams
• Scheduling permit issuance
• Score reporting to IMGs

What this replaced: Previously, IMGs submitted exam applications through ECFMG, which also managed eligibility and issued scheduling permits.

Phase 2 (January 2026): US student Step 3 moves to NBME

NBME (National Board of Medical Examiners) now manages all three USMLE Step exams for US/Canadian medical students and graduates. Previously, Step 3 was handled by FSMB for US students.

What Changed for IMGs

What Did NOT Change for IMGs

This is critical. Many IMGs are confusing the administrative transition with changes to ECFMG Certification requirements. Nothing changed about ECFMG Certification itself.

• ECFMG Certification requirements are identical. You still need Step 1 + Step 2 CK + OET Medicine + an approved ECFMG Pathway.
• ECFMG still determines certification eligibility. ECFMG reviews your credentials and decides whether you qualify for certification.
• ECFMG still receives your USMLE scores. The USMLE program reports scores directly to both the IMG and ECFMG.
• Scheduling at Prometric is unchanged. After receiving your scheduling permit from FSMB, you book your exam at Prometric exactly as before.
• The 7-year rule is unchanged. All ECFMG certification requirements must be completed within 7 years of your first passed USMLE exam.
• ECFMG Pathways are unchanged. The six Pathways for clinical/communication skills verification remain the same.

Step-by-Step: How to Register as an IMG in 2026

If you are an IMG applying for a USMLE Step exam for the first time, or if you have questions about navigating the new system, follow these steps:

Step 1: Complete ECFMG certification prerequisites

Before applying for any USMLE Step exam, confirm your eligibility:

• Your medical school is listed in the World Directory of Medical Schools
• Your school meets ECFMG requirements
• You have completed the basic science curriculum (required for Step 1)

If you are a graduate, ensure your diploma has been verified by ECFMG through primary source verification.

Step 2: Create an account on the FSMB USMLE portal

Go to fsmb.org and create an account on the FSMB USMLE portal. This is where you will manage all USMLE Step exam applications as an IMG.

Important: Do not confuse the FSMB USMLE portal with the old ECFMG portal or MyIntealth. MyIntealth (managed by ECFMG) is where you manage your ECFMG Certification application, and that process is unchanged.

Step 3: Submit your exam application through FSMB

Apply for your Step exam through the FSMB USMLE portal. You will need:

• Personal identification information (name must exactly match what will appear on your ID on test day)
• Medical school documentation
• Payment (Step 1: $695, Step 2 CK: $695)

Step 4: Wait for your scheduling permit

After your application is approved and eligibility confirmed, FSMB will issue your scheduling permit. The permit specifies your eligibility period (a 3-month window during which you can schedule your exam).

Step 5: Book your Prometric appointment

With your scheduling permit in hand, go to prometric.com, select your exam, choose a testing center, and book your date. For IMGs who must travel internationally (India has no Prometric centers), book as early as possible because popular centers fill up months in advance.

Step 6: Confirm your ECFMG Certification progress separately

Your ECFMG Certification application continues through MyIntealth (ECFMG's portal). Once you pass Step 1 and Step 2 CK and satisfy all Pathway requirements, ECFMG issues your ECFMG Certificate. This process is entirely separate from the FSMB exam registration process.

ECFMG Pathways: A 2026 Overview

ECFMG requires IMGs to demonstrate clinical and communication skills through one of six Pathways. All Pathways share a common requirement: OET Medicine (Occupational English Test for medicine).

The six Pathways accommodate different types of graduates:

• Pathway 1: Accreditation-based (school has ACGME-I or Royal College accreditation for specific programs)
• Pathway 2: USMLE Step 2 CS or equivalent exam-based (clinical skills examination)
• Pathway 3: Postgraduate training-based (completed graduate medical education in certain countries)
• Pathway 4: Licensure-based (current medical license in good standing in approved jurisdictions)
• Pathway 5: Healthcare experience-based (supervised direct patient care)
• Pathway 6: Medical school attestation-based (school attests student competency)

Which Pathway applies to you depends on your country, your school's accreditation, your postgraduate training, and your current licensure status. Review the ECFMG Pathways FAQ at ecfmg.org for your specific situation.

OET Medicine

The Occupational English Test (OET) Medicine is now required for all ECFMG Pathways. It tests English language proficiency in a medical context, covering listening, reading, writing, and speaking in clinical scenarios. Minimum score requirements apply to each subtest.

For most Indian, Pakistani, Filipino, and Caribbean graduates, English proficiency is not a significant barrier. However, the OET Medicine has specific medical vocabulary and clinical communication requirements that benefit from targeted preparation.

Canadian Graduates: A New Opportunity

A significant change took effect in 2025: graduates of Canadian medical schools from July 2025 onward can now apply for ECFMG Certification, opening the possibility of US residency matching through the IMG pathway. Previously, Canadian graduates applying for ECFMG was not available in the same way.

If you are a Canadian medical graduate considering the US pathway, confirm your eligibility through ecfmg.org.

Frequently Asked Questions

Can I still access my old ECFMG portal?

The ECFMG portal (MyIntealth) remains active for ECFMG Certification purposes, including credential verification, Pathway applications, and ECFMG Certificate management. However, USMLE exam applications and scheduling permits are now managed through FSMB, not ECFMG.

Where do I check my USMLE scores?

Scores are reported through the USMLE program. As an IMG, you will receive score notification through FSMB. ECFMG also receives your scores directly for certification purposes.

Does this transition affect my scheduling permit if I already have one?

No. Existing scheduling permits issued before January 12, 2026 remain valid. If your permit is current and you have not yet taken your exam, proceed as normal. Contact FSMB if you have questions about an existing permit.

Do I need to transfer my ECFMG account to FSMB?

No. These are separate systems for separate purposes. Your ECFMG/MyIntealth account manages your ECFMG Certification application. Your FSMB USMLE portal account manages your USMLE Step exam applications. Both accounts can (and should) exist simultaneously.

Who do I contact for questions about my exam application?

Contact FSMB for questions about USMLE Step exam applications, eligibility periods, scheduling permits, and exam fees. Contact ECFMG for questions about ECFMG Certification, credential verification, and ECFMG Pathways.

Does the transition affect the 7-year rule?

No. The 7-year rule (all ECFMG certification exam requirements must be completed within 7 years of your first passed exam) is set by ECFMG and is unchanged.

Will the FSMB portal work for both Step 1 and Step 2 CK?

Yes. The FSMB USMLE portal manages both Step 1 and Step 2 CK for IMGs. All Step exam applications go through FSMB.

What if I took Step 1 before the transition and need to apply for Step 2 CK now?

Apply for Step 2 CK through the FSMB USMLE portal. Even if your Step 1 application was submitted through ECFMG before January 12, 2026, all new applications go through FSMB.

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