USMLE Service Transition 2026: The Complete IMG Guide

Effective January 12, 2026, the USMLE program transferred all International Medical Graduate exam services — registration, scheduling permits, eligibility management, and score delivery — from ECFMG to the Federation of State Medical Boards (FSMB). Concurrently, US student Step 3 services moved from FSMB to NBME.

The organizational change was administrative, not academic: exam content, scoring, and ECFMG Certification requirements are unaffected. But for IMGs, the immediate practical question is straightforward: which portal do I use now, and what do I need to do differently?

This guide walks through the transition mechanics, the new registration workflow, and the answers to every common question that has surfaced since the January cutover.

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

A widespread misunderstanding has conflated the portal migration with changes to ECFMG Certification standards. The certification requirements were not modified. ECFMG Certification requirements (Step 1 + Step 2 CK + OET Medicine + approved Pathway), certification eligibility determination, score reporting to ECFMG, Prometric scheduling, the 7-year completion rule, and all six ECFMG Pathways are unchanged.

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.

What to Do If Your Application Is in Limbo

During major administrative transitions, some applications fall between systems. If you submitted an application through the old ECFMG portal before January 12, 2026 and have not received confirmation from the new FSMB system, follow this escalation sequence:

Step 1: Check the FSMB portal first. Your application data should have been migrated automatically from ECFMG to FSMB. Log in to the FSMB USMLE portal and look for your application status there, not at the old ECFMG portal.

Step 2: If your application does not appear in FSMB, contact FSMB support directly. Have your ECFMG ID number, old portal confirmation numbers, and payment receipts ready. FSMB support can trace migrated applications using your ECFMG ID as a reference.

Step 3: If you are within 60 days of your planned exam date and the application is still unresolved, escalate by contacting both FSMB and ECFMG simultaneously. Reference your scheduling permit timeline and the urgency of your testing window. Applications stuck in migration limbo near an exam date should be treated as time-sensitive by both organizations.

Score reporting during the transition: Your existing score history is maintained regardless of the administrative transition. Scores earned under the ECFMG system are fully recognized under the FSMB system. You do NOT need to retake any exams because of the portal change.

ECFMG certification is still managed by ECFMG. The transition only affects exam registration and scheduling. Do not confuse "FSMB now handles exam services" with "ECFMG no longer matters." ECFMG Certification requirements (Step 1, Step 2 CK, and Pathway fulfillment) remain unchanged and are still administered by ECFMG. Your MyIntealth account for ECFMG Certification is entirely separate from your FSMB exam registration account.

Service Transition: IMG 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.

Navigate the transition smoothly and keep your prep on track — sign up for free question access at quantaprep.com.