TITLE 22. EXAMINING BOARDS

PART 9. TEXAS MEDICAL BOARD

CHAPTER 161. PHYSICIAN LICENSURE

The Texas Medical Board (Board) proposes new rule §161.48, concerning Physician Graduates, and new rule §161.53, concerning Provisional License to Foreign Medical License Holders with Offers of Employment.

These rules are mandated by the passage of HB 2038 (89th Regular Legislative Session) which amended the Texas Occupations Code Chapter 155. HB 2038, known as the "DOCTOR Act," provides new pathways to licensing foreign trained physicians and medical school graduates who do not match into a resident training program.

The proposed new sections are as follows:

New §161.48, Physician Graduates, provides a pathway for certain individuals to be issued a limited license under to practice medicine under a supervising practice agreement with a sponsoring physician. The Bill provides that the Board shall issue a license to an individual who has graduated from a board-recognized accredited medical school in the United States or Canada or a medical school located outside of the United States and Canada that the board recognizes as acceptable; be licensed and in good standing to practice medicine in another country; has passed the first and second components of the USMLE; and is not enrolled in a board-approved postgraduate residency program. The bill requires the Medical Board to adopt rules as necessary to implement the new provisions of the Texas Occupations Code.

New §161.53, Provisional License to Foreign Medical License Holders with Offers of Employment, provides that the Board shall issue an initial provisional license to practice medicine to an applicant who: has been granted a degree of doctor of medicine by a program of medical education that meets eligibility requirements for the applicant to apply for certification by the Educational Commission for Foreign Medial Graduates; has been licensed in good standing to practice medicine in another country and is not the subject of any pending disciplinary action before the licensing body; has completed a residency or a substantially similar postgraduate medical training required by the applicant's country of licensure; passes the Texas medical jurisprudence examination; has proficiency in the English language; is authorized under federal law to work in the United States; has been offered employment in this state as a physician by a person who provides health care services in the normal course of business in a facility-based or group practice setting, including a health system, hospital, hospital-based facility, freestanding emergency facility, or urgent care clinic; has passed the first and second steps of the USMLE examination.

Scott Freshour, General Counsel for the Texas Medical Board, has determined that, for each year of the first five years the proposed new sections are in effect, the public benefit anticipated as a result of enforcing these proposed sections will be to increase the number of healthcare providers in Texas and thereby expand healthcare for the citizens of Texas.

Mr. Freshour has also determined that for the first five-year period these proposed new sections are in effect, there will be no fiscal impact or effect on government growth as a result of enforcing the proposed sections.

Mr. Freshour has also determined that for the first five-year period these proposed new sections are in effect there will be no probable economic cost to individuals required to comply with these proposed sections except as they relate to licensure fees.

Pursuant to Texas Government Code §2006.002, the agency provides the following economic impact statement for these proposed new sections and determined that for each year of the first five years these proposed new sections will be in effect there will be no effect on small businesses, micro businesses, or rural communities. The agency has considered alternative methods of achieving the purpose of these proposed new sections and found none.

Pursuant to Texas Government Code §2001.024(a)(4), Mr. Freshour certifies that this proposal has been reviewed, and the agency has determined that for each year of the first five years these proposed new sections are in effect:

(1) there is no additional estimated cost to the state or to local governments expected as a result of enforcing or administering these proposed new sections;

(2) there are no estimated reductions in costs to the state or to local governments as a result of enforcing or administering these proposed new sections;

(3) there is no estimated loss but there may be an increase in revenue to the state or to local governments as a result of enforcing or administering these proposed new sections; and

(4) there are no foreseeable implications relating to cost or revenues of the state or local governments with regard to enforcing or administering these proposed and new sections.

Pursuant to Texas Government Code §2001.024(a)(6) and §2001.022, the agency has determined that for each year of the first five years these proposed new sections will be in effect, there may be an effect on local economy and local employment by virtue of attracting new healthcare practitioners to the state.

Pursuant to Government Code §2001.0221, the agency provides the following Government Growth Impact Statement for the proposed new rules. For each year of the first five years the proposed new rules will be in effect, Mr. Freshour has determined the following:

(1) the proposed rules do not create or eliminate a government program;

(2) implementation of the proposed rules does not require the creation of new employee positions or the elimination of existing employee positions;

(3) implementation of the proposed rules does not require an increase or decrease in future legislative appropriations to the agency;

(4) the proposed rules do require an increase in fees paid to the agency;

(5) the proposed rules do create a new regulation;

(6) the proposed rules do not expand, limit, or repeal an existing regulation;

(7) the proposed rules do increase the number of individuals subject to the rule's applicability; and

(8) the proposed rules positively affect this state's economy.

Comments on the proposal may be submitted using this link https://forms.cloud.microsoft/g/LF8Nq11i55.

SUBCHAPTER J. LIMITED LICENSES

22 TAC §161.48

The proposed new rule(s) are proposed pursuant to the passage of HB 2038 (DOCTOR Act) (89th Regular Legislative Session) which added Texas Occupations Code Sections 155.1015 and 155.201-155.212, and requires the Board to adopt rules to implement such sections. Specifically, 155.1015 and 155.202, respectively, provide authority for the Board to recommend and adopt rules to implement and regulate these new licenses and licensees. No other statutes, articles or codes are affected by this proposal.

§161.48. Physician Graduates.

(a) All applicants for a Physician Graduate License must meet the general eligibility requirements set forth in §155.203 of the Act and submit:

(1) a completed board-required application form;

(2) the required application fee;

(3) additional fees and surcharges as applicable;

(4) documentation of the following:

(A) proof of residency in Texas;

(B) proof of US citizenship, legal permanent residency in the US, or federal work authorization;

(D) proof of ECFMG certification for international medical school graduates;

(E) passage of the Texas Jurisprudence examination with at least a score of 75;

(F) certified transcript of Examination Scores documenting passage within three attempts of the first and of the second components of an examination in accordance with §155.0511 of the Act;

(G) attestation of no current enrollment in a board-approved postgraduate residency program;

(H) documentation of prior enrollment in a board-approved postgraduate residency program, if applicable;

(I) all disciplinary history related to any professional license, if applicable;

(J) FBI/DPS Fingerprint Report;

(K) alternate name or name change, if applicable;

(L) medical school transcript, if requested;

(M) arrest records, if applicable;

(N) malpractice records, if applicable;

(O) treatment records for alcohol or substance use disorder or any physical or mental illness impacting the ability to practice, if applicable; and

(P) any other documentation deemed necessary to process an application.

(b) Applications are valid for one year from the date of submission. The one-year period can be extended for the following reasons:

(1) delay in application processing;

(2) referral of the applicant to the Licensure Committee;

(3) unanticipated military assignments, medical reasons, or catastrophic events; or

(4) other extenuating circumstances.

(c) The board may allow substitute documents where exhaustive efforts on the applicant's part to secure the required documents are presented.

(d) A sponsoring physician of a physician graduate must submit an attestation confirming they meet the criteria of §155.205 of the Act and submit a supervising practice agreement that documents:

(1) the position offered to the physician graduate;

(2) description of the medical services and specialty medical services to be provided by the physician graduate in accordance with §155.205(a)(4) of the Act;

(3) physical address of the work location for the physician graduate and sponsoring physician;

(4) description of the on-site supervision arrangement; and

(5) the number of clinical hours to be practiced by the physician graduate.

(e) A sponsoring physician may authorize a physician graduate to practice under the delegation and supervision of one other physician, in accordance with §155.206(c) of the Act.

(f) A sponsoring physician is limited to sponsoring only two physician graduates.

(g) A sponsoring physician is subject to all provisions of Chapter 157 of the Act; however, if any provision in Chapter 155, Subchapter E of the Act imposes stricter requirements, those shall prevail.

(h) Physician graduate medical practice is subject to the limitations and required disclosures set forth in §155.207 of the Act, in addition to the following:

(1) The physician graduate's practice is limited to the confines of the location documented in the supervising practice agreement submitted to the Board by the sponsoring physician;

(2) A physician graduate may not have more than one supervising practice agreement;

(3) A physician graduate is limited to no more than 60 clinical hours per week;

(4) The sponsoring physician or other properly designated physician under §155.206 of the Act must be on-site at all times when the physician graduate is practicing;

(5) The physician graduate license holder is not authorized to delegate to or supervise anyone;

(6) The physician graduate is not authorized to order or prescribe a controlled substance listed as a schedule II;

(7) Mandatory updates shall be reported to the Board by the physician graduate license holder and sponsoring physician within 10 days in accordance with §162.2 of this title (relating to Profile Updates), including, but not limited to, matching in an approved postgraduate training program;

(8) The physician graduate must cease practice immediately in the event of the loss of employment and/or sponsoring physician, for any reason;

(9) The physician graduate has 60 days to obtain a new position and a new sponsoring physician and shall not practice until a new sponsoring physician is obtained and approved by the Board;

(10) At the end of the 60-day period, if the physician graduate does not have employment and a sponsoring physician, the physician graduate license shall be automatically terminated; and

(11) If a physician graduate license is terminated, the physician graduate must submit a new application and meet all eligibility requirements set forth in this subchapter.

(i) Registration and Renewal of Physician Graduate License

(1) Within 90 days of a license being initially issued, it must be registered by:

(A) completing a board registration form;

(B) submitting the initial registration fee of $541, and additional fees and surcharges, as applicable;

(D) providing other relevant information requested by the board staff.

(2) Subsequent renewal is biennially by:

(A) completing a board renewal form;

(B) submitting payment of a biennial renewal fee of $537, and additional fees and surcharges, as applicable;

(D) completing biennial continuing medical education (CME) required under Chapter 156 of the Act and Chapter 161, Subchapter H of this title (relating to Continuing Medical Education Requirements for License Renewal);

(E) documentation of meeting all qualifications under Section 155.203 of the Act;

(F) submission of renewal attestation form completed by the sponsoring physician;

(G) if there is a new sponsoring physician designated the renewal will not be granted until the qualification of the new sponsoring physician and a new supervising practice agreement is filed and verified by Board staff; and

(H) providing other relevant information requested by board staff.

(3) Failure to renew before a license's expiration date will result in increased charges as follows:

(A) 1-90 days late--renewal fee plus one half of the renewal fee; and

(B) 91 days-1 year late--double the renewal fee.

(4) Failure to renew within one year after the expiration date of the license will result in cancellation of the license.

(j) A physician graduate license holder is subject to board rules, including rules regarding complaints, investigations, and disciplinary sanctions and procedures of the board.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on October 22, 2025.

TRD-202503815

Scott Freshour

General Counsel

Texas Medical Board

Earliest possible date of adoption: December 7, 2025

For further information, please call: (512) 305-7059

SUBCHAPTER K. TEMPORARY LICENSES

22 TAC §161.53

§161.53. Provisional License to Foreign Medical License Holders with Offers of Employment.

(a) All applicants for an Initial Provisional License must:

(1) meet the general eligibility requirements set forth in §155.1015(a) - (d) of the Act;

(2) declare the area of medical specialty in which they will practice; and

(3) meet the criteria under subsection (b)(5) of this section.

(b) All applicants must submit a completed application for licensure and all documents and information necessary to complete an applicant's request for licensure including, but not limited to:

(1) the required application fee;

(2) additional fees and surcharges, as applicable;

(3) proof of ECFMG certification;

(4) licensure verification form from the licensing body of the other country as required by §155.1015(a)(2) of the Act;

(5) proof of completion of a residency or a substantially similar postgraduate medical training required by applicant's country of licensure that is in the same specialty as the area of medicine the applicant will practice in while under the Provisional License; and:

(A) is recognized as substantially similar by the board; or

(B) completion of a comprehensive competency evaluation administered by a board-approved assessment program, with a favorable recommendation regarding competency and proficiency in the area of specialty practice in which they will practice;

(6) passage of the Texas Jurisprudence examination with at least a score of 75;

(7) copy of federal work authorization;

(8) copy of offer of employment to practice only in:

(A) a facility-based or group practice setting as set forth in §155.1015(d) of the Act; and

(B) the specialty that applicant declared in the application;

(9) certified transcript of Examination Scores documenting passage of USMLE Step 1 within three attempts and USMLE Step 2 within three attempts;

(10) FBI/DPS Fingerprint Report;

(11) documentation of alternate name or name change, if applicable; and

(12) medical school transcript, if requested;

(13) specialty board certification, if applicable;

(14) arrest records, if applicable;

(15) malpractice records, if applicable;

(16) all disciplinary history related to any professional license, if applicable;

(17) copies of all comprehensive competency evaluations administered by a board-approved assessment program demonstrating competency and proficiency in the area of specialty practice in which they will practice, if applicable;

(18) treatment records for alcohol or substance use disorder or any physical or mental illness impacting the ability to practice, if applicable;

(19) Professional or Work History Evaluation forms demonstrating or relating to the practice of medicine in the area of the declared specialty for the preceding two years from the date of the application as a physician; and

(20) any other documentation deemed necessary to process an application.

(c) Any document received from a direct third-party or primary source that is in a language other than the English language must:

(1) have a certified translation prepared;

(2) be translated by a translation agency that is a member of the American Translations Association or a United States college or university official;

(3) be verified by the translator as a "true word for word" translation; and

(4) be included with the copy of the translation.

(d) Initial Provisional License Standards:

(1) The initial provisional license is valid for two years.

(2) Practice is limited as set forth in §155.1015(d) of the Act.

(3) The initial provisional license holder is not authorized to delegate or supervise.

(4) Mandatory updates shall be reported to the Board by the initial provisional license holder and employer within 10 days in accordance with §162.2(b) of this title (relating to Profile Updates), including, but not limited to, any change in status of the provisional holder's license in another country on which the provisional license was granted.

(5) If employment is terminated for any reason the license is placed in a suspended status and, the provisional license holder must;

(A) cease practice immediately;

(B) notify the Board in writing within 48 hours of termination;

(D) submit to and obtain approval from the Board of the qualified employer.

(6) Failure to report, to the Board, within 48 hours of termination eliminates the 60-day period to find new employment and the provisional license is automatically canceled effective on the date of termination.

(7) The two-year duration of the initial provisional license will be tolled while the provisional license holder attempts to obtain qualified employment. The two-year duration will be extended for the number of days equal to the number of days between ending and beginning qualified employment. Any extension of the initial provisional license's two-year duration is not to exceed a maximum of 60 days. If the provisional license holder is unable to obtain qualified employment within 60 days, or the total extensions during the initial provisional license period exceeds 60 days, then the initial provisional license is terminated.

(8) In the event of termination of the provisional license holder's employment, the employer's medical director, chief medical officer, lead physician, or supervising physician shall ensure written notice to the Board within 72 hours of the termination.

(9) If a provisional license holder does not fully complete their initial provisional license period, for any reason, they will receive no credit for prior initial provisional practice time and:

(A) may reapply for a second initial provisional license; and

(B) may be required to appear before the licensure committee of the Board;

(10) An applicant is limited to a maximum of two initial provisional licenses.

(11) A Provisional License Holder is limited to practicing in the area of medical specialty declared in the Provisional License Holder's approved application.

(12) The provisional license holder must comply with the Continuing Medical Education (CME) requirements set out in Subchapter H, §161.35 of this title (relating to Continuing Medical Education (CME) Requirements for License Renewal). The applicant must create and utilize an account with the Board approved CME tracker for tracking and meeting the CME requirements.

(e) All applicants for a Second Provisional License must meet the general eligibility requirements set forth in §155.1015(e) and (f) of the Act and submit a completed application for licensure and all documents and information necessary to complete an applicant's request for licensure including, but not limited to:

(1) completion of a two-year period during an initial provisional license;

(2) the required application fee;

(3) additional fees and surcharges as applicable;

(4) all disciplinary history related to any professional license, if applicable;

(5) Professional or Work History Evaluation form from first provisional employer;

(6) copy of employment offer that meets the criteria set forth in §155.1015(f) of the Act;

(7) successful remediation of deficiencies identified in the comprehensive competency assessment evaluation completed for issuance of the initial provisional license, if applicable;

(8) any other documentation deemed necessary to process an application; and

(9) If a pathway to board specialization exists for a Provisional License Holder from an organization recognized by the Board through §164.4 of this title (relating to Advertising Board Certification), the certification granting organization must submit a letter, on behalf of the provisional license holder, of satisfactory progress towards board specialization eligibility.

(f) Second Provisional License Standards:

(1) The second provisional license is valid for two years.

(2) Practice is limited as set forth in §155.1015(f) of the Act.

(3) The second provisional license holder may delegate or supervise.

(4) Mandatory updates shall be reported to the Board by the second provisional license holder and employer within 10 days in accordance with §162.2 of this title, including, but not limited to, any change in status of the provisional holder's license in another country on which the provisional license was granted.

(5) If employment is terminated for any reason, the provisional license holder must;

(A) cease practice immediately;

(B) the license is suspended automatically;

(D) submit to and obtain the approval of the Board proof of qualified employer.

(6) Failure to make the report within 48 hours of termination eliminates the 60-day period to find new employment and the provisional license is automatically canceled effective on the date of termination.

(7) The two-year duration of the second provisional license will be tolled while the provisional license holder attempts to obtain qualified employment. The two-year duration will be extended for the number of days equal to the number of days between ending and beginning qualified employment. Any extension of the second provisional license's two-year duration is not to exceed a maximum of 60 days. If the provisional license holder is unable to obtain qualified employment within 60 days, or the total extensions during the second provisional license period exceeds 60 days, then the second provisional license is terminated.

(9) If a provisional license holder does not fully complete their second provisional license period, for any reason, they will receive no credit for prior second provisional practice time and;

(A) may reapply for a second initial provisional license; and

(B) may be required to appear before the licensure committee of the board;

(10) An applicant is limited to a maximum of two second provisional licenses.

(11) A Provisional License Holder is limited to practicing in the area of medical specialty declared in the Provisional License Holder's approved application.

(12) the provisional license holder must comply with the Continuing Medical Education (CME) requirements set out in Subchapter H, §161.35 of this title. The applicant must create and utilize an account with the Board approved CME tracker for tracking and meeting the CME requirements.

(g) All applicants for a Full License must meet the general eligibility requirements set forth in §155.1015(g) and (h) of the Act and must submit a completed application for licensure and all documents and information necessary to complete an applicant's request for licensure including, but not limited to:

(1) certified transcript of Examination Scores documenting passage of each part of USMLE within three attempts and within seven years;

(2) proof of completion of an Initial Provisional and Second Provisional for the requisite time periods as set forth in subsections (d) and (f) within a period of five years, in total, calculated from the first day of an Initial Provisional license to the last day of a Second Provisional license;

(3) If a pathway to board specialization exists for a Provisional License Holder from an organization recognized by the Board through §164.4 of this title, the certification granting organization must submit a letter, on behalf of the provisional license holder, of satisfactory progress towards board specialization eligibility;

(4) Professional or Work History Evaluation form from second provisional employer; and

(5) any other documentation deemed necessary to process an application.

(h) Applications are valid for one year from the date of submission. The one-year period can be extended for the following reasons:

(1) delay in processing application;

(2) referral of the applicant to the Licensure Committee;

(3) unanticipated military assignments, medical reasons, or catastrophic events; or

(4) other extenuating circumstances.

(i) The board may allow substitute documents where exhaustive efforts on the applicant's part to secure the required documents are presented.

(j) A Provisional License holder is subject to board rules, including rules regarding complaints, investigations, and disciplinary procedures and sanctions of the board.

(k) The Executive Director may approve reasonable deviations from the required provisional licensee timelines due to extenuating circumstances. The provisional licensee may appeal the Executive Director's decision to the Licensure Committee.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on October 22, 2025.

TRD-202503816

Scott Freshour

General Counsel

Texas Medical Board

Earliest possible date of adoption: December 7, 2025

For further information, please call: (512) 305-7059