Chronic Conditions Management
From 1 July 2025, Medicare Benefits Schedule (MBS) items will be changing to replace the current GP Management Plan (GPMP) and Team Care Arrangements (TCA) with a single GP Chronic Condition Management (CCM) Plan.
Changes to Chronic Disease Management
New GP Chronic Conditions Management (GPCCM) MBS items commence from, 1 July 2025.
From 1 July 2025 the Department of Health and Aged Care has announced major changes to the MBS framework for chronic disease management in primary care will come into effect. These changes implement the recommendations of the MBS Review Taskforce. This new Chronic Condition Management model simplifies how care plans are created and reviewed, improving access and continuity for patients managing long-term conditions.
Key updates include:
- A single GP chronic condition management plan replaces current GPMP and TCA items
- Referral letters will replace existing allied health referral forms
- Equalised fees for preparation and review of plans ($156.55 for GPs)
- MyMedicare-registered patients must access GPCCMP services through their registered practice; non-registered patients may use their usual GP
- Multidisciplinary team requirements have been simplified – the previous requirement to collaborate with two providers has been removed. Multidisciplinary care plan items (e.g., 231, 232, 729, 731) are not affected by this reform
- Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers can now assist in preparing or reviewing a plan
- Patients must have had a plan prepared or reviewed within the last 18 months to access MBS-funded allied health services
- A plan can be prepared once every 12 months, and reviews can occur every 3 months. A new plan each year is not required—existing plans can be reviewed
Current plans remain valid during a 2-year transition period until 30 June 2027.
These changes aim to streamline care and support better outcomes for patients with chronic conditions.
Factsheets
- Existing Chronic Disease Management (CDM) Plans and referrals will remain valid until July 2027. There is no need to take immediate action to transition CDM patients to new GPCCMPs.
- Use the new GPCCM MBS item numbers (see table below) in place of the ceased CDM item numbers. When billing any new GPCCM plans or undertaking reviews of a Chronic Disease Management (CDM) plan, use the MBS item numbers for an initial GP Chronic Condition Management Plan (GPCCMP) [965, 392, 29029, 29060]. This is necessary as GPCCMP Review item numbers are not able to be claimed unless a new GPCCMP has been billed.
- If you are a MyMedicare practice, encourage any patients with a CDM plan or GP Chronic Condition Management Plans (GPCCMPs) to register with your practice for MyMedicare.
Table 1: GP Chronic Condition Management Items commencing 1 July 2025
| Name of Item | GP MBS items | Prescribed medical practitioner MBS items |
| Prepare a GP chronic condition management plan – face to face | 965 | 392 |
| 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 |
For more information on GPCCM changes, MBS Online has released a series of factsheets here:
For support on MyMedicare, GPCCM change queries, and quality improvement support, please contact Adelaide PHNs, Practice Support team at practicesupport@adelaidephn.com.au
The full item descriptor(s) and information on other changes to the MBS can be found on the MBS Online website. You can also subscribe to future MBS updates by visiting ‘Subscribe to the MBS’ on the MBS Online website.
Providers seeking advice on interpretation of MBS items, explanatory notes and associated legislation can use the department’s email advice service by emailing askMBS@health.gov.au
MBS items. Chronic Conditions Management (CCM) MBS item changes recommended by the MBS Review Taskforce are ‘the first major change to chronic disease management in 20 years, and are scheduled to come into effect 1 July 2025’.
Substantial changes are coming to how chronic conditions are managed in general practice. Starting from 1 July 2025, new CCM MBS items recommended by the MBS Review Taskforce will take effect.
Start preparing your general practice now, change can feel overwhelming, but breaking it down into small, practical steps makes it easier. Australian general practices already use great methods like Plan–Do–Study–Act cycles to adapt and improve while keeping things running smoothly.
To help your practice prepare, APHN is launching a CCM activation series. This series will guide your team and patients in implementing the new items and strengthening patient connections through MyMedicare.
Other steps your practice can take to prepare now
Here are some other ideas you might like to consider preparing for Chronic Conditions Management and MyMedicare patient registration:
- Discuss what these changes mean with your practice team. Identify any processes you need to review or update (e.g. incorporate MyMedicare registration in your chronic disease management workflows).
- Register your practice for MyMedicare if you have not done so already.
- Encourage your patients with a chronic condition or existing care plan to register with MyMedicare:
- frequently asked questions to use in conversations with patients.
- Include the MyMedicare Registration form and brochure with your patient consent form
- Update your practice website to include links to MyMedicare patient registration information.
- Place MyMedicare posters and brochures in your practice waiting room/reception and display MyMedicare Patient videos in your waiting room screens.
- Post information about MyMedicare in your practice social media page using Social Media Tiles.
For further information, please contact your Adelaide PHN Practice Support contact or email practicesupport@adelaidephn.com.au
CCM activities:
Focus on engaging patients with Chronic Disease Management Plans and team care arrangements, encouraging them to register with MyMedicare and return for regular reviews.
Build awareness among your team about MyMedicare and the CCM changes and explore how everyone can play a role in these updates.
Plan-Do-Study-Act (PDSA) Template for General Practices
Chronic Condition Management Toolkit
The Chronic Conditions Management (CCM) QI Toolkit provides a practical guide to help general practices implement continuous Quality Improvement (QI) activities for managing chronic conditions.
It supports primary care teams in delivering structured, proactive, and person-centred care — enhancing continuity, improving patient outcomes, and increasing efficiency. The toolkit aligns with the revised Chronic Condition Management (CCM) MBS items and the Strengthening Medicare reforms, coming into effect from 1 July 2025.
Navigating this Toolkit
This toolkit includes flexible, practical activities designed to meet your practice’s unique needs. Activities are not intended to be completed in sequence — you can start where it makes the most sense for your team.
We recommend starting with Module 1 – Practice Readiness to assess your current state and prepare for the upcoming MBS changes.