Chronic Condition Management

From 1 July 2025, there will be a new framework for chronic disease management and GP Management Plans and Team Care Arrangements will be replaced with a single GP Chronic Condition Management Plan (GPCCMP).  

The changes to the MBS framework aim to simplify, streamline, and modernise the arrangements for health professionals. 

Who is eligible for a GPCCMP 

A GPCCMP is intended to support patients who would benefit from a structured approach to their care.  The GPCCMP is available to patients with at least one medical condition that has been (or is likely to be) present for at least six months or is terminal.  It is up to the GP or Prescribed Medical Practitioner’s (PMP) 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. 

Patients registered with MyMedicare will be required to access the GPCCMP and review items through the practice where they are registered. 

Best Practice Software has provided resources to assist practices with the transition

 Transition arrangements - in place for 2 years 

The changes taking effect on 1 July 2025 apply to NEW plans for patients with a chronic condition and new referrals written under existing GPMPs and TCAs, or new GPCCMPs.

For patients that have a GPMP and/or TCA in place prior 1 July 2025 there is no immediate action required. 

Patients can continue to access allied health and other services under their existing plans until 30 June 2027. Referrals written prior to 1 July 2025 will continue to be valid until all services under that referral have been provided.

Please view the Services Australia transition arrangements fact sheet for more detailed information.

MBS items

From 1 July 2025 the following MBS items will cease:

• GP management plans – 229, 721, 92024, 92055
• Team care arrangements – 230, 723, 92025, 92056
• Reviews – 233, 732, 92028, 92059

These changes do not affect multidisciplinary care plan items (231, 232, 729, 731, 92026, 92027, 92057, 92058). 

 The new GPCCMP and review items commencing 1 July 2025 can be conducted in person or via telehealth.  

Items for the preparation or review of a GPCCMP cannot be co-claimed on the same day as general attendance items.  GPCCMP items may be claimed with single bulk billing incentives when eligible patients are bulk billed and will be included in the Bulk Billing Practice Incentive Program from 1 November 2025. 

Preparation of a GPCCMP

Practice Nurses, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers can assist the General Practitioner in the preparation of the GPCCMP. Unless exceptional circumstances apply, a GPCCMP can be prepared once every 12 months (if necessary).  

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 

The requirement to have at least 2 collaborating providers on a plan has been removed. 

Review of a GPCCMP 

Practice Nurses, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers can assist the General Practitioner in the review of a GPCCMP.

Unless exceptional circumstances apply, a GPCCMP can be reviewed every 3 months, if it is clinically relevant to do so. It is not required that a new plan be prepared each year, an existing GPCCMP can be reviewed and amended on an ongoing basis. 

If a patient requires a review of a GPMP or TCA that was put in place prior to 1 July 2025 they will need to have a new GPCCMP prepared. Patients will need to have their GPCCMP prepared or reviewed in the previous 18 months to continue to access allied health services. 

Please read the Services Australia upcoming changes to chronic disease management framework - MBS items for GPs fact sheet which includes more detailed information about MBS items, preparation and reviewing a GPCCMP.

Referrals to allied health services and multidisciplinary teams

Any referrals for allied health services written prior to 1 July 2025 will remain valid until all services under the referral have been provided.

Referrals can be signed and transmitted electronically where possible. There is no requirement for allied health providers to confirm acceptance of the referral or otherwise provide input into the preparation of the GPCCMP. 

If the patient is to be referred to a member of a multidisciplinary team, the GP or PMP must obtain the patient’s continued consent to sharing relevant information with the multidisciplinary team.  If the patient consents to sharing this information, the GP must provide relevant updated parts of the plan to the members of the multidisciplinary team, in addition to the referral. 

Referrals do not need to:  

• Specify the name of the allied health provider to provide the services. A patient can take a referral to physiotherapy services under their GPCCMP to a physiotherapist of their choice.
• Specify the number of services to be provided. 

New referral requirements do not apply to other MBS-supported allied health services, including Better Access psychological therapy services, focussed psychological strategies (allied mental health) services, eating disorder allied health services, or diagnostic audiology services. 

Please read the Services Australia referral arrangements for allied health services fact sheet which includes more detailed information about new referral guidelines.