Business Skills: GPCCMP plans in practice

Overview 

The new GP chronic condition management plan (GPCCMP) supports access to MBS-subsidised services for chronic conditions. 

Effective from 1 July 2025, the Medicare Benefits Schedule (MBS) will replace GP management plans (GPMPs) and team care arrangements (TCAs) with a single MBS item 965, which allows vocationally-registered GPs to prepare a GPCCMP during a face-to-face consultation, and item number 92029 for preparation by video consult. 

Before July 2025:

• $157.60 for preparing an annual GP management plan (item 721)

•  $124.15 for a team care arrangement (item 723) which required written confirmation from at least two allied health providers before submission - often delaying care and revenue 

• $82.10 for each of GPMP and TCA review (item 732); these items could be prepared together

Assuming three GPMP and TCA reviews annually (every three months), the total annual billing per eligible patient was $779.15. However, Medicare item reports show that GPMP and TCA reviews were infrequently billed. Whilst the potential total billings of the new item numbers is less than the old, in practice, the streamlined approach to using the new item numbers should result in a revenue bump for most GPs.

GPMPs lasted for up to two years, but eventually needed replacing, as did the TCA, although they could be rebilled every 12 months.

After 1 July 2025: 

• the GPCCMP replaces the GPMP and TCA 

• GPCCMP preparation (item 965), and each review (item 967) are billed at $156.55

• where clinically appropriate, one annual preparation and three reviews (every three months) is allowed and would result in total annual billings of $626.20 per patient 

• GPCCMPs do not expire, however, patients must have had a GPCCMP or review done in the last 18 months to have ongoing access to MBS-subsidised allied health services

Table 1: MBS Item Numbers for GP Chronic Disease Management – Face to Face (GPs Only)

Allied health involvement

Note that allied health provider confirmation of acceptance to be part of the team is no longer required before billing the GPCCMP. This means the plan can be completed and billed on the same day, reducing administrative delays and workload, and allowing faster access to funding. 

Additionally, referrals to allied health professionals have been simplified. The older requirement for Enhanced Primary Care referral forms has been removed, with standard referral letters - the same as those used for other specialists - now accepted. The referrals to allied health services will be valid for 18 months from the date of the first service provided under the referral.

Important billing considerations and transition arrangements

• Item numbers 721, 723 ,and 732 will cease on July 1st 2025

• A 965 can first be claimed 3 months and 1 day after the last 721 or 732. 

• For patients requiring a review of their GPMP or TCA after July 1st 2025, a new GPCCMP needs to be created with item number 965

• Item number 967 (for reviews) cannot be billed unless a 965 has been billed previously

• Item numbers for preparation of a GPCCMP may be billed once every 12 months, unless there is a significant change in the patient’s condition

• These new item numbers cannot be billed on the same day as general attendance items (eg, 23, 36, 44). 

Workflow tip: do a search for all GPMPs claimed in the last 12 months and compare with the number of reviews done (using tools like Cubiko). Use this to estimate the impact of changes, and to allocate staff and budgeting.

Patient eligibility criteria for GPCCMPs:

• billing for MyMedicare enrolled patients can occur at their enrolled practice only; patients not enrolled can have a GPCCMP at their regular GP 

• GPCCMPs are for patients with one or more chronic conditions who would benefit from a structured approach to their care 

• the condition(s) must have been or must be likely to be present for more than 6 months (there is no list of eligible conditions - GP s will need to use their discretion to decide on this) 

• patients cannot be enrolled in a residential aged care facility 

Workflow tip: improve continuity of care by encouraging your patients to enrol in MyMedicare.

The core components of a GPCCMP

To meet Medicare requirements, the preparation of a GPCCMP must involve the development of a comprehensive written plan that includes the following elements:

1. diagnosis and clinical context: a clear description of the patient’s chronic condition(s) and associated health care needs

2. patient-centred goals: documented health and lifestyle goals, developed collaboratively through a shared decision-making approach between the patient and the medical practitioner

3. patient actions: specific actions the patient agrees to undertake in support of their treatment and self-management

4. planned treatments and services: details of the treatment and services the patient is likely to require to manage their condition(s), including any routine care and monitoring

5. multidisciplinary care (if applicable): where appropriate, the plan must outline any additional health or community services to which the patient will be referred, including the purpose of those services

6. review arrangements: clear arrangements for monitoring progress and reviewing the plan, including a proposed timeframe for the next review 

The transition to the GP chronic condition management plan (GPCCMP) from 1 July 2025 represents a major reform in chronic disease management. By aligning workflows with the new item structure, general practices can enhance access to care, maintain continuity for patients, and improve operational efficiency - while supporting the financial sustainability of chronic care delivery.

Free downloadable resource - workflow tips and reference guide

A printable resource with workflow tips and a reference guide for the new item numbers can be downloaded here.

References

Department of Health, Disability and Ageing. Upcoming Changes to Chronic Disease Management Framework - MBS Items for GP Chronic Condition Management Plans. 2025. (last accessed June 2025).

Department of Health, Disability and Ageing. Upcoming Changes to Chronic Disease Management MBS Items - Transition Arrangements for Existing Patients. 2025. (last accessed July 2025).

RACGP. Summary of changes to Chronic Disease Management (CDM) Framework. 2025. (last accessed June 2025).

Department of Health, Disability and Ageing. Upcoming Changes to Chronic Disease Management Framework - Overview. 2025. (last accessed June 2025).

Department of Health and Aged Care. Medicare Benefits Schedule - Item 965. 2025. (last accessed July 2025). 

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