USMLE for IMGs: Step 1, Step 2 CK, ECFMG and the Match

This guide is for doctors and medical students trained outside the United States who want a US residency. You pass USMLE Step 1 and Step 2 CK, become ECFMG certified (which includes an English test, OET Medicine), apply through ERAS and the NRMP Match, and start training on a J-1 or H-1B visa; Step 3 usually comes later.

Before your first exam

Step 1 and Step 2 CK are open to students and graduates of medical schools outside the US that are listed in the World Directory of Medical Schools with an ECFMG Sponsor Note covering your graduation year.

Open a MyIntealth account with ECFMG (part of Intealth), verify your identity and submit the Application for ECFMG Certification. It must be accepted before you register for an exam.
Create an account in FSMB’s USMLE portal. Since 12 January 2026, the Federation of State Medical Boards, not ECFMG, has handled USMLE registration, scores and extensions for IMGs.
Apply for a Step, choose a three-month eligibility period and book a Prometric seat as soon as your scheduling permit arrives.

The three Steps at a glance

In 2026 all three Steps moved to new software with 30-minute blocks of up to 20 questions (Step 3 in March, Step 1 and Step 2 CK in May); the number of questions and the testing time are unchanged. From January 2029, the three Steps will together be offered on only 45 designated days a year.

	Step 1	Step 2 CK	Step 3
Format	1 day, 8 hours, 14 blocks	1 day, 9 hours, 16 blocks	2 days: about 7 hours (232 questions) and about 9 hours (180 questions plus 13–14 case simulations)
Result	Pass/fail	Three-digit score, pass mark 218	Three-digit score, pass mark 200
Where	Test centres worldwide	Test centres worldwide	US and its territories only

Results usually arrive within four weeks.

Step 1 and Step 2 CK scores

Step 1 has been pass/fail since 26 January 2022, so Step 2 CK is the only certification exam with a numerical score – and the one programmes compare. Its pass mark rose from 214 to 218 for exams taken from 1 July 2025.

Step 3: after certification

Step 3 requires passes in Step 1 and Step 2 CK and a valid ECFMG Certificate. USMLE recommends sitting it after, or near the end of, your first residency year. Its pass mark will be reviewed in November 2026; any change would apply from 1 January 2027.

Attempt limits

You may sit the same Step no more than three times in 12 months. After four unsuccessful attempts at a Step, incomplete ones included, you can no longer apply for any Step.

ECFMG certification

ECFMG certification is required to enter an ACGME-accredited residency and to sit Step 3. You need:

exams: Step 1 and Step 2 CK, passed within seven years of the first exam you pass;
clinical and communication skills: one of ECFMG’s Pathways, including OET Medicine;
credentials: your final diploma and transcript, which ECFMG verifies directly with your school.

OET Medicine: the English requirement

You need at least 350 in Listening, Reading and Speaking and 300 in Writing in one sitting; miss one score and you retake all four sub-tests. For the 2027 Pathways the test must date from 1 January 2025 or later. Results take about ten working days, so for the 2027 Match ECFMG advises testing by the last December 2026 date. OET@Home is accepted only if your country has no test venue.

Choosing a Pathway

Applications for the 2027 Pathways close on 31 January 2027; the fee is US$945.

Pathway 1: you held a licence to practise without supervision at any time on or after 1 January 2022. Training and restricted licences do not count.
Pathway 2: at an eligible school, you passed a clinical skills exam (OSCE) that your country’s regulator requires for licensure.
Pathways 3–5: your school is accredited by an agency recognised by WFME (3) or found comparable by NCFMEA (4), or awards a joint degree with an LCME-accredited US school (5); the school attests your clinical skills. Check ECFMG’s list of eligible schools.
Pathway 6: everyone else. Licensed physicians assess six real outpatient encounters in person using the Mini-CEX; evaluations are due by 15 February 2027.

Pathways 2–5 require graduation on or after 1 January 2024; current students can also apply.

ERAS and the Match

Most programmes take applications through the AAMC’s ERAS, which IMGs access with a token from ECFMG; emergency medicine and obstetrics and gynaecology use ResidencyCAS instead. Positions are filled through the NRMP Main Residency Match. Key dates for training starting in 2027:

Date	What happens
24 June 2026	ECFMG releases ERAS tokens
2 September 2026	Applications can be sent to programmes
15 September 2026	NRMP registration opens
23 September 2026	Programmes start reviewing applications
29 January 2027	Standard NRMP registration deadline (US$50 late fee afterwards)
31 January 2027	Deadline for Pathway applications; OET scores must have reached ECFMG
3 March 2027	Rank order list deadline: Step 1, Step 2 CK and your Pathway must be complete
19 March 2027	Match Day
About 1 July 2027	Training begins

In the 2026 Match, 56.4% of non-US-citizen IMGs matched to a first-year position – the lowest rate in five years; for foreign-born IMGs needing visa sponsorship it was 54.4%. Check each programme’s graduation-year limits and the visas it sponsors.

Visas: J-1 or H-1B

J-1

ECFMG sponsors J-1 visas for physicians in clinical training. You need a Statement of Need in which the health ministry of your country of nationality or last permanent residence confirms that it needs doctors in your specialty and that you have promised to return. Sponsorship is generally limited to seven years. You must then leave within 30 days and spend two years in your home country before qualifying for certain other US visa statuses (INA §212(e)).

H-1B

For an H-1B, an IMG in a patient-care post needs passes in all three Steps, an ECFMG Certificate and any licence the state requires – so Step 3 comes before residency.

Changes to check

Entry restrictions: since 1 January 2026, Proclamation 10998 has suspended J visas for nationals of 38 countries, including Iran, Sudan, Syria, Nigeria and Venezuela; for 19 of them every visa type, H-1B included, is suspended. Exceptions are narrow.
Social media: J-1 and H-1B visa applicants must set their profiles to public.
US$100,000 H-1B payment: introduced in September 2025 for new petitions for people outside the US and extended until September 2027, but blocked by federal courts in Massachusetts (June 2026) and California (September 2026); in late October 2026 it was not being collected. The government is appealing, so check USCIS’s current guidance.
J-1 length of stay: a DHS rule to replace “duration of status” with a fixed admission period of up to four years (extendable through USCIS) has been on hold by court order since 14 September 2026 while the case continues.

What it costs

Item	Fee (October 2026)
MyIntealth account (incl. online notarisation)	US$110
Application for ECFMG Certification	US$580
Verification of diploma and transcript	US$220
FSMB USMLE account	US$75
Step 1 / Step 2 CK outside the US and Canada, incl. region fee	US$905 / US$930
OET Medicine	AU$587 (US$455 on computer in the US)
Pathway application	US$945
ERAS token	US$185
USMLE transcript for ERAS (once per season)	US$70
ERAS programme fees	US$11 each for the first 30 programmes per specialty, then US$30 each
NRMP registration	US$85 for up to 20 ranked programmes, then US$30 each
Step 3	US$955
J-1 sponsorship and SEVIS fee	US$370 + US$220

Fixed fees up to Match Day come to just over US$4,000 before OET and ERAS programme fees; applying to 100 programmes in one specialty adds US$2,430.

How to prepare

Plan backwards from September. Have your Step 2 CK result before you apply, and book OET early enough to resit it before the December cut-off.
Practise in the new format. Work in 30-minute blocks and use the free sample questions in the interactive testing experience on usmle.org.

How MedMigrant can help

If you are weighing the US against other countries, or need help preparing documents for recognition abroad, MedMigrant offers individual consultations on recognition. MedMigrant is independent of USMLE, FSMB, ECFMG, the AAMC and the NRMP.

Frequently asked questions

Can I take Step 1 and Step 2 CK while still at medical school?

Yes, if you are officially enrolled at an eligible school and your Application for ECFMG Certification has been accepted. Certification itself comes only after ECFMG has verified your diploma.

Do I need a medical licence from my own country?

No, neither the exams nor certification require one. A full licence to practise without supervision can, however, open Pathway 1.

Can I retake a Step to improve my score?

No. A passed Step can be retaken only in narrow cases, such as meeting a time limit set by a US licensing authority.

Do I need Step 3 before residency?

Not for ECFMG certification or a J-1, but an H-1B requires it – and you can sit it only once you are certified.

Sources

Last updated: 28 October 2026. Rules, dates and fees change, and the official websites listed above are decisive.

USMLE for IMGs: Step 1, Step 2 CK, Step 3 and ECFMG Certification