TMB Adopts Rules for Two New Physician License Categories Amid Visa Impediments for IMGs
By Phil West and Amy Lynn Sorrel

However, federal and state impediments to certain nonimmigrant work visas could halt the law’s progress, which the Texas Medical Association is investigating. 

As of this writing, IMGs requiring H-1B work visas were still not exempt from a $100,000 fee established by a September 2025 presidential proclamation, an exemption organized medicine requested last fall. Gov. Greg Abbott instituted a subsequent freeze on new H1-B visa petitions by state universities and agencies in Texas on Jan. 27. 

TMA President Jayesh “Jay” Shah, MD, says IMGs represent a significant contribution to Texas’ physician workforce at about 25%. He expressed “grave concerns” the H-1B visa interruptions could harm recruitment and access to care, as well as the potential for the new law to help “rural and underserved areas that may be able to take advantage of hiring these physicians and who are ready to serve and ready to work.” 

Referred to as the DOCTOR Act, House Bill 2038 created a provisional license for IMGs and a limited license for unmatched physician graduates. Online applications are expected to be available on the TMB website starting sometime in February, an agency spokesperson says.  

Championed by Reps. Tom Oliverson, MD (R-Cypress), and Suleman Lalani, MD (D-Sugar Land), the law aims to provide pathways for the two new classes of license holders to practice medicine while providing rural patients with greater statewide access to care.  

In a September 2025 message preceding the release of the rules, TMB President Sherif Zaafran, MD, indicated the board expects high standards for the new license classes.  

“We are committed to ensuring that this pathway does not create a class of ‘second-tier’ physicians,” he said.  

Applicants must follow certain CME, documentation, disciplinary, and other existing requirements for physician licensure. 

Provisional licenses for IMGs

In addition, among other requirements, for an IMG to secure an initial two-year provisional license to practice medicine in Texas, the candidate must: 

• Meet specific requirements relating to foreign medical education, postgraduate medical training, and licensure. 

• Have an offer of employment in Texas in a facility-based or group practice setting providing health care services. 

• Declare which medical specialty they’ll practice in, and the written offer of employment must be in an applicant’s declared specialty, with proof of specialty board certification if applicable. 

• Report changes in employment status. 

IMGs who secure an initial two-year provisional license can apply for a second two-year provisional license. Those second provisional license holders “may practice only in a rural community or medically underserved area or health professional shortage area, as designated by the United States Department of Health and Human Services, that has a current shortage of physicians,” the law states.  

Following two cycles of provisional licenses, those IMG physicians can then apply for full physician licensure. Those who do not apply are no longer able to practice once the second provisional two-year license expires. 

Limited licenses for unmatched grads

Unmatched physician graduates securing or renewing a newly established limited license must practice exclusively in counties with populations under 100,000.  

Application requirements include unique eligibility requirements related to testing and medical school. Limited licensees also must:  

• Have no current enrollment in a board-approved postgraduate residency program. 

• Enter into a supervising practice agreement with an eligible sponsoring physician and have only one supervising practice agreement at a time, with practice limited to the location listed in the agreement.  

• Not exceed 60 clinical hours per week with the sponsoring physician or authorized delegate on-site at all times the physician graduate is practicing.  

• Limit practice to the specialty of the sponsoring physician’s board certification.   

• Not supervise or delegate to other individuals or prescribe Schedule II controlled substances.   

Dr. Shah is optimistic the involvement of unmatched physician graduates could give their physician sponsors more time and more capacity to care for patients.  

“They should be able to help those supervising physicians decrease their workload and increase access [to care], because if you have two people working at the same time, they can see more patients,” he said.  

Questions remain about how many applicants will surface. TMA staff calculated that only 19 Texas fourth-year medical students were unmatched in 2025, and Medicare has communicated with TMA it’s uncertain whether Medicare will pay for services provided by physician graduates, as it’s not a health care profession the payer recognizes.       

Find more information on the DOCTOR Act in TMA’s whitepaper webpage under licensing (member login required). And learn more about Texas’ physician workforce needs.   

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