Show Menu +

Chronic conditions management

In line with recommendations made by the Australian Government’s MBS Review Taskforce, there is a new framework for chronic conditions management.

The changes, implemented 1 July 2025, promote continuity of care and regular reviews for patients with chronic conditions, and enhance communication within multidisciplinary teams.

The framework replaces GP management plans (GPMP) and team care arrangements (TCA) with a single GP chronic condition management plan (GPCCMP).

Associated MBS items have also changed:

Old items New items MBS benefit
Preparation of a GP management plan/coordination of team care arrangements Prepare a GP chronic condition management plan
721,723
92024, 92025
General practitioner
Face to face: 965
Video: 92029
$156.55
229, 230
92055, 92056
Prescribed medical practitioner
Face to face: 392
Video: 92060
$125.30
Review of a GP management plan or coordination of a review of team care arrangements Review a GP chronic condition management plan
732
92028
General practitioner
Face to face: 967
Video: 92030
$156.55
233
92059
Prescribed medical practitioner
Face to face: 393
Video: 92061
$125.30

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

Practice nurses, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers can continue to contribute to the preparation of a GPCCMP and the ongoing review, as under the current framework.

The requirement to consult with collaborating providers, such as allied health and medical specialists, when creating a care plan has been removed.

  • Allied health visits and referrals

    The number of visits available under chronic condition management plan is unchanged. The available allocations remain:

    • Up to five individual allied health services per calendar year, or 10 for patients of Aboriginal or Torres Strait Islander descent.
    • Up to five 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 eight group services for the management of diabetes per calendar year.

    The requirement to have at least two collaborating providers has been removed. Referrals are now in the form of letters, consistent with those to medical specialists.

    Referral letters do not need to specify the name of an allied health provider. A generic referral to ‘physiotherapist’, for example, allows the patient to attend an allied health professional of their choosing.

    There is no need to specify the number of sessions for each referral. However, it may be useful to include this information if visits will be divided between different providers.

    An allied health provider is not required to acknowledge a referral, but must report to the referring practitioner after the first and last service.

  • Transition for patients with existing chronic disease management items

    For patients with a GPMP or TCA in place before 1 July 2025 no immediate action is required. Access to services provided through MBS item 10997 and its telehealth equivalents 93201 and 93203 continues until 30 June 2027.

    Referrals for allied health services written prior to 1 July 2025 will remain valid until all services under the referral have been provided, as long as these are completed by 30 June 2027.

    Any patient requiring a review of an existing GPMP or TCA should be transitioned to a GPCCMP.

    Referral for allied health services should meet the updated referral requirements, regardless of whether it is made under a GPMP, TCA or GPCCMP.

    From 1 July 2027

    • All CCM patients will need to be transitioned to a GPCCMP to have ongoing access to allied health and other services.
    • Patients will require a GPCCMP to be eligible for a Department of Health, Disability and Ageing Home Medicines Review.
  • Resources to support your practice

    Your relationship manager can support your practice through this transition – contact our Primary Care Team on 9347 1188, or at primarycare@nwmphn.org.au to arrange one-on-one support.