Chronic Conditions Management – MyMedicare Changes
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Changes to General Practitioner Chronic Conditions Management Framework and MBS Items came into effect 1 July 2025.
This page provides guidance and support to those working in primary care to enhance understanding of changes when engaging in Chronic Conditions Management.
The content on this page has been derived from published information by the Australian Government, Department of Health, Disability and Aging, as well as Services Australia.
On this page
Table 1: GP Chronic Condition Management Items as of 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:
GPCCM MBS Online FAQs and Overview - Note AN.0.47 | Medicare Benefits Schedule
MBS Online - Upcoming changes to the MBS Chronic Disease Management Framework
Frequently Asked Questions (FAQs)
Encourage any patients with a CDM plan or a GP Chronic Condition Management Plan (GPCCMP) to register with your practice for MyMedicare.
- Explain to patients that MyMedicare establishes a unique link to the general practice they wish to see for their ongoing care and management of their chronic health condition/s.
- If a patient does not wish to register for MyMedicare, they should be reassured that MyMedicare is voluntary and that they can continue to access chronic condition care and GPCCMPs through their usual practice.
- If a patient is signed up with MyMedicare at an alternative practice, they must access any GPCCMP items through the practice that they are registered with.
According to Services Australia, the patient’s usual medical practitioner or someone at the same practice should bill GPCCMP items.
You’re a patient’s usual medical practitioner if you, or are located at a medical practice that either:
- has provided the majority of services to the patient in the past 12 months
- will provide the majority of services in the following 12 months.
Noting that patients registered through MyMedicare must access GPCCMP items through the practice where they are registered.
Existing Chronic Disease Management (CDM) Plans and referrals will remain valid until July 2027.
When undertaking a review of a General Practitioner Management Plan (GPMP), also referred to as a Chronic Disease Management (CDM) plan, use the MBS items for an initial GPCCMP (965, 392, 29029, 29060) - see Table 1 for details.
This is necessary as the GPCCMP Review item numbers are not able to be claimed unless a new GPCCMP has been billed.
No.
In an aim to simplify, streamline, and modernise the arrangements for health care professionals and patients, a Team Care Arrangement (TCA) is no longer required when referring a patient to allied health services associated with a GPCCMP.
In place of the TCA, providers will now be required to refer directly to an allied health provider via a standard referral letter.
Additionally, it is no longer a requirement to receive a sign-off from the allied health provider accepting involvement in the TCA.
Once every three months.
Note: Services Australia indicate that you can provide these services more frequently in exceptional circumstances. For example, when there is a significant change in a patient’s condition.
Tip: Ensure to schedule regular GPCCMP reviews at the conclusion of each new GPCCMP or review appointment. Clearly explain the care planned for the next review to each patient.
No.
Patients can receive 5 individual services each calendar year.
Referrals under a GPCCMP are valid for the timeframe stated in the referral. If there’s no timeframe stated, they’re valid for 18 months from the first service date provided under the referral.
Yes.
Practice nurses and Aboriginal and Torres Strait Islander health practitioners can provide support on behalf of medical practitioners up to 5 services per calendar year for a patient who has a current GPCCMP.
These services must be:
- provided on behalf of and under the supervision of the eligible practitioner.
- consistent with the patient’s CCM plan.
Item Numbers
Face-to-face: Item 10997 | Medicare Benefits Schedule
Video: Item 93201 | Medicare Benefits Schedule
Telephone: Item 93203 | Medicare Benefits Schedule
Billing Resources
See more information on MBS Online Note MN.12.4 | Medicare Benefits Schedule.
See more information on the Correct billing of Medicare Benefits Schedule (MBS) item 10997.
Chronic Condition Management Case Studies
If a MyMedicare registered patient attends multiple general practice locations or GPs, for different types of health care.
- The patient should ensure they register for MyMedicare at the practice where they intend to receive ongoing, continuous primary care services, including GP chronic condition management plan preparation and review services.
- They can still visit alternative GP practices for services that are not MyMedicare linked items, such as when requiring a medical certificate, script or referral for blood tests.
If a MyMedicare registered patient’s preferred GP works from multiple locations for the same practice (which is not a hub and spoke arrangement) and the patient visits this GP at more than one location.
- The patient, provider and practice should ensure that any GP chronic condition management plan preparation and review services are delivered at the practice location where the patient is registered for MyMedicare.
- The patient can visit the preferred GP at other locations for other services that are not linked to MyMedicare, such as when requiring a medical certificate, script or referral for blood tests.
If a MyMedicare registered patient’s preferred GP works across multiple practices (not just different locations of the same practice) and the patient visits them at different practices depending on where the GP is consulting on the day.
- The patient can only access GP chronic condition management plan preparation and review services at the practice location where they are registered with MyMedicare.
- The patient cannot access these services at other practices, even if their preferred GP is working there. However, the patient can visit the preferred GP at other locations for services that are not linked to MyMedicare, such as when requiring a medical certificate, script or referral for blood tests.
- The patient and provider should ensure that all GP chronic condition management plan preparation and review appointments are booked at the practice location where the patient is registered in MyMedicare.
If a patient is registered with MyMedicare at a ‘Hub and Spoke’ practice (which is available to ACCHS and AMS) and they usually attend a local clinic (a ‘spoke’) but sometimes visit the main clinic (the ‘hub’) for additional services.
- The patient can access GP chronic condition management plan preparation and review services at their registered practice ‘hub’ or any of its ‘spoke’ locations. These services can be delivered by any eligible provider linked to the ‘hub’, at either the ‘hub’ or any of its ‘spoke’ locations, not just their preferred GP. They cannot access these services at another practice or ‘hub’ where they are not registered.
- The patient, provider and practice should ensure that the patient is registered for MyMedicare at the ‘hub’ to enable access to both ‘hub’ and ‘spoke’ locations. GP chronic condition management plan preparation and review appointments can then be booked at the ‘hub’ or one of its linked ‘spoke’ locations.
Case Study 1: MyMedicare Patient Registrations
Background
Amina is a patient who regularly visits two different general practices. She sees her longtime family doctor at Practice A for ongoing health concerns, such as managing her asthma and monitoring her blood pressure. However, when she needs a quick medical certificate for work, she visits Practice B, which is closer to her office.
What happens for Amina from 1 July 2025
Patients like Amina can continue to access GP chronic condition management plan preparation and review services from their usual GP - even if they are not registered for MyMedicare.
If Amina chooses to register for MyMedicare, she will need to nominate a single practice (Practice A) as her MyMedicare practice. Once registered she can access GP chronic condition management plan preparation and review services from Practice A. Amina can continue to visit Practice B for consultations not directly related to management of her chronic condition or other MyMedicare linked services, such as medical certificates, scripts or a referral for blood tests.
Action required
If Amina registers for MyMedicare at Practice A, she will need to access all GP chronic condition management and care planning services from this practice. This includes ensuring that any telehealth appointments for these services are also booked at Practice A.
Case Study 2: Managing CCM Appointments for MyMedicare Registered Patients Across Multiple Practice Locations
Background
Connor is a MyMedicare registered patient whose preferred GP works at two different locations within the same general practice - Location A and Location B. Connor books appointments based on where his GP is working on a given day, attending either location or via telehealth as needed. The practice is not set up in MyMedicare as a ‘hub and spoke’ model (available to ACCHS and AMS) and Connor has registered with MyMedicare at Location A.
What happens for Connor from 1 July 2025
Because Connor is registered for MyMedicare, he accesses GP chronic condition management plan preparation and review services at the specific practice location where he is registered (Location A). If Connor’s GP is working at Location B, Connor can book appointments for services unrelated to his GP Chronic Condition Management Plan at this location. This could range from a script, medical certificate or referrals for blood tests or radiography, for example. For any medical issues associated with his chronic condition or other MyMedicare linked services, Connor will need to make an appointment at Location A.
Action required
Connor and his practice team will need to schedule all GP chronic condition management plan preparation and review appointments at Location A. This includes ensuring that any telehealth appointments for these services are also linked to Location A.
Case Study 3: Managing CCM Appointments for MyMedicare Registered Patients when their preferred GP Works at Multiple Practices
Background
Sarah is a MyMedicare registered patient who follows her preferred GP, Dr. O’Brian, for allher healthcare needs. Dr. O’Brian works part-time at two entirely separate general practices, Practice X and Practice Y. Sarah books appointments at either practice depending on Dr. O’Brian’s schedule.
What happens for Sarah from 1 July 2025
Because Sarah is registered for MyMedicare at Practice X, she can access GP chronic condition management plan preparation and review services at this practice. These services can be delivered by any eligible provider at Practice X, not just Dr. O’Brian.
Even if Dr. O’Brian is consulting from Practice Y, Sarah cannot access GP chronic condition management plan preparation and review services at that practice. These services are available from the practice where she is officially registered. However, she can continue to access other services from Dr O’Brian at Practice Y if they are not directly related to management of her chronic condition or other MyMedicare linked services, such as medical certificates, scripts and referrals for blood tests or radiology services.
Action required
Sarah needs to book all GP chronic condition management plan preparation and review appointments at Practice X, where she is registered. This includes ensuring that any telehealth appointments for these services are also linked to Practice X.
Case Study 4: Managing CCM Appointments for MyMedicare Registered Patients Registered at Practices using the ‘Hub and Spoke’ Model
Background
Leah is a MyMedicare registered patient who receives care through an Aboriginal Medical Service (AMS) that operates under a MyMedicare ‘hub and spoke’ model. She usually visits the ‘spoke’ clinic in her local community for regular check-ups and health advice but occasionally travels to the main ‘hub’ clinic.
What happens for Leah from 1 July 2025
Because Leah is registered for MyMedicare at a practice that is set up as a ‘hub and spoke’ model, she can access GP chronic condition management plan preparation and review services at either the ‘hub’ or any of its ‘spoke’ locations.
However, Leah cannot access these MyMedicare-linked services at another practice or ‘hub’ where she is not registered, even if she sees her preferred provider there.
Action required
Leah and her care team need to ensure that all GP chronic condition management plan preparation and review services are delivered through her registered practice ‘hub’ or one of its linked ‘spoke’ locations. This gives her flexibility to receive care close to home while still benefiting from coordinated services across the network.
Practice Resources
Training and Education
- WVPHN LEARN: Medicare Changes with Care Plans: Where to from here?
- RACGP: National member webinar: Chronic condition management update (16 October 2025)
- Cubiko: Pt. 1 - Everything you need to know about the new Chronic Condition Management announcements (24 June 2025)
- Cubiko: Pt. 2 - Everything you need to know about the new Chronic Condition Management announcements (9 July 2025)
- Services Australia: Requirements for a chronic condition management plan
- Bp Premier Spectra: FAQ: GP Chronic Condition Management Plan (GPCCMP) (10-12 June 2025)
- Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans (22 May 2025)
- RACGP: Summary of changes to Chronic Disease Management (CDM) Framework.
How we can support you
Western Victoria Primary Health Care Primary Care Engagement Officers (formally known as the practice facilitation team) are available for support.
Contact us to help you
- Using data to improve patient care and identify patients who may require a GPCCMP
- MyMedicare support
- My Health Record support
- Connecting practices with Allied Health
- Accreditation Support
- Adaptation of workflows
- Identify resources to support your conversations with patients
- Connecting to you eLearning and resources
- Linking your practice to digital health support
- MBS clarification and workflow management
To request a visit from your Primary Care Engagement Officer, please visit the Primary Care Engagement Officer Visits page.