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From 1 July 2025, Medicare Benefits Schedule (MBS) changes will streamline chronic care with a single GP Chronic Condition Management Plan (GPCCMP). This aims to simplify allied health referrals and support continuity through MyMedicare.
Chronic disease is a growing problem and a leading cause of illness, disability and mortality. Chronic Conditions Management (CCM) MBS item changes recommended by the MBS Review Taskforce are the first major change to the chronic disease management framework in 20 years and are scheduled to come into effect on 1 July 2025.
The changes aim to simplify, streamline and modernise the arrangements for health care professionals and patients, promote continuity of care, encourage the regular review of chronic condition management plans, support communications between a patient’s multidisciplinary care team and ensure existing patients can continue to access the care they need.
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New resources to support your general practice in making small manageable changes and adapt to the new CCMP changes:
Watch the recording of the CCM information session to get all the key updates and insights.
Please contact Medicare Reform to ask any questions around the changes or request support by emailing: medicare.reform@ntphn.org.au
You can also read our CCM FAQÂ Factsheet.
MBS Online has released a selection of factsheets:
MBS Online – Upcoming changes to the MBS Chronic Disease Management Framework
The PHN strongly encourage you to read these fact sheets and share the information with your team.
Ceased item numbers:
New item numbers:
| Name of item | GP item number | Rebate | Prescribed medical practitioner item number |
Rebate |
|---|---|---|---|---|
| Prepare a GP chronic condition management plan – face to face |
965 | $156.55 | 932 | $125.30 |
| Prepare a GP chronic condition management plan - video |
92029 | 92060 | ||
| Review a GP chronic condition management plan – face to face |
967 | 393 | ||
| Review a GP chronic condition management plan – video |
92030 | 92061 |
These changes do not affect multidisciplinary care plan items (231, 232, 729, 731, 92026, 92027, 92057, 92058).
Please refer to the following MBS Multidisciplinary Care Team items table for more information.
The MBS fee to prepare and review a GPCCMP is $156.55 for GPs and $125.30 for PMPs.
Preparing a GPCCMP:
• Unless exceptional circumstances apply, a GPCCMP can be prepared once every 12 months if it is clinically relevant to do so. It is not required that a new plan be prepared each year, existing plans can continue to be reviewed.
• A GPCCMP is intended to set out the patient’s treatment and management goals, actions to be taken and, where multidisciplinary care is required and the services to which the patient will be referred.
• The plan is intended to be a patient-centred plan. While there are a range of MBS supported services available for patients with a GPCCMP, services that are supported through other funding mechanisms can also be identified in the plan.
• Subject to the patient’s consent, GPs and PMPs are encouraged to upload the GPCCMP to My Health Record.
Reviewing a GPCCMP:
A key objective of the changes to the arrangements for chronic condition management is to encourage regular reviews of GPCCMPs. An existing GPCCMP can be reviewed and amended on an ongoing basis.
• The new MBS items to review a GPCCMP should only be used to review an existing GPCCMP. If a patient requires a review of a GPMP or TCA that was put in place prior to 1 July 2025 they should be transitioned to the new arrangements through the preparation of a GPCCMP.
• A GPCCMP can be reviewed every 3 months if it is clinically relevant to do so. Increased frequency of reviews may be approved if exceptional circumstances apply.Â
Patients can access the following MBS-supported services where they are consistent with their GPCCMP:
• Up to 5 individual allied health services per calendar year (10 services for patients of Aboriginal or Torres Strait Islander descent).
• Up to 5 services provided on behalf of a medical practitioner by a practice nurse or Aboriginal and Torres Strait Islander Health Practitioner.
• For patients with type 2 diabetes, an assessment of their suitability for group dietetics, diabetes education or exercise physiology services and, if they are suitable, up to 8 group services for the management of diabetes per calendar year.
Eligible patients:
• GPCCMPs are for patients with one or more chronic medical conditions who would benefit from a structured approach to their care.
• A chronic medical condition that has been (or is likely to be) present for at least 6 months or is terminal.
• There is no list of eligible conditions. It is up to the GP or PMP’s clinical judgment to determine whether an individual patient with a chronic condition would benefit from a GPCCMP.
• GPCCMPs are not available to patients who are care recipients in a residential aged care facility. Allied health services are available to these patients through a multidisciplinary care plan.
Transition arrangements for existing patients:
Patients that had a GP management plan and/or team care arrangement in place prior to 1 July 2025 will be able to continue to access services consistent with those plans for two years. From 1 July 2027, a GP chronic condition management plan will be required for ongoing access to allied health services.
• Patients can continue to access services provided through MBS item 10997 (and its telehealth equivalents 93201 and 93203) under existing GPMPs and TCAs until 30 June 2027
• Individual and group allied health services can be accessed under existing GPMPs and TCAs until 30 June 2027.
From 1 July 2027, a GP chronic condition management plan will be required for ongoing access to allied health services.
• Referral forms replaced by referral letters, consistent with medical specialist referrals.
• No prescribed form needed – letters must include practitioner details, date, reason for referral, and be signed (can be electronic).
• Referrals valid for 18 months from the first service (unless otherwise specified).
• No need to name a specific provider or number of sessions – patients have greater choice.
• Applies to Groups M3, M8, M9, M10 (subgroup 1), and M11. Please refer to the allied health group table below.
• Allied health providers must still report back to the GP after certain services (e.g., first and last).
• Electronic referrals encouraged to reduce lost paperwork.
• Changes do not apply to Better Access, eating disorders, or diagnostic audiology services.
Allied Health Services MBS Grouping
| Allied Health Services Group | Description |
|---|---|
| Group M3 (subgroup 1) | Individual allied health services for patients with a chronic condition (referred under the chronic conditions management arrangements). |
| Group M8 | Pregnancy support counselling allied health services. |
| Group M9 | Allied health group services for patients with type 2 diabetes (referred under the chronic conditions management arrangements). |
| Group M10 (subgroup 1) | Complex neurodevelopmental disorders and eligible disabilities allied health services. |
| Group M11 | Allied health services for Aboriginal and Torres Strait Islander people (referred under the chronic conditions management arrangements or following a health assessment). |