GPCCMP FAQ - Understanding GPCCMP & Key Changes
Transitioning Existing Patients & Plans – How to move existing care plan patients smoothly into GPCCMP.
Staff Roles & Responsibilities – Clarifies who does what in GPCCMP workflows, from GPs to nurses and admin staff.
Specific Patient Groups & Edge Cases – Advice for managing complex patients and uncommon GPCCMP scenarios.
Practice Management & Clinical Software – Guides for using clinical software and Cubiko tools to support GPCCMP workflows.
Patient Communication & Operational Planning – Templates and tips for engaging patients and planning care delivery efficiently.
MyMedicare Requirements – What practices and patients need to know about MyMedicare registration and eligibility.
MBS Item Numbers & Billing – Understand which MBS items apply, how to claim correctly and avoid common billing errors.
GPCCMP Plan Creation & Reviews – Step-by-step guidance for creating, reviewing and updating GP Chronic Care Management Plans.
Financial Strategy & Practice Efficiency – Practical tips to improve billing accuracy, profitability and workflow efficiency.
Compliance & Quality Assurance – Stay compliant with RACGP, Medicare and MyMedicare requirements when delivering care plans.
Allied Health Referrals Under GPCCMP – How to manage allied health referrals linked to GP Chronic Care Management Plans.
What is the GPCCMP and how is it different from current GPMPs and TCAs?
The Bottom Line:
The GP Chronic Condition Management Plan (GPCCMP) is the new, streamlined approach to managing chronic health conditions, replacing the previous GP Management Plans (GPMPs) and Team Care Arrangements (TCAs). This shift simplifies care planning by consolidating two separate plans into one comprehensive plan, with practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers now formally able to assist with preparation and reviews.
The Facts:
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From 1 July 2025, GPMPs and TCAs are replaced with a single GP chronic condition management plan (GPCCMP)
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The GPCCMP introduces a single, streamlined approach, moving your team from managing two separate planning processes to one
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A GPCCMP outlines the patient's chronic conditions, care goals, treatment actions, referrals (if needed), and a review schedule
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Under the new framework, the requirement for GPs or Prescribed Medical Practitioners (PMPs) to consult with at least two collaborating providers as part of a Team Care Arrangement (TCA) has been removed
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GPs and PMPs can now refer patients with a GPCCMP directly to relevant services without requiring allied health providers to confirm acceptance of the referral
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Referrals to allied health providers will be made via a standard referral letter, no longer requiring a structured Medicare form
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New MBS item numbers apply for GPCCMP preparation and review: 965 (GP face-to-face), 92029 (GP telehealth video), 392 (PMP face-to-face), and 92060 (PMP telehealth video) for plan development; and 967 (GP face-to-face), 92030 (GP telehealth video), 393 (PMP face-to-face), and 92061 (PMP telehealth video) for plan reviews, replacing all existing GPMP and TCA items
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The ability for practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers to assist in the preparation of a GPCCMP has been specified in the regulatory arrangements for the new items
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Patients registered with MyMedicare will be required to access GPCCMP services through their registered practice, enhancing continuity of care, while patients not registered with MyMedicare can access these services at any practice but should use their usual GP
Sources: Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet; MBS Items for GP Chronic Condition Management Plans – Factsheet; What Do the Changes Mean for Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers? – Factsheet; MBS Online explanatory note AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6
Links and Resources:
Official Information:
Implementation Support:
Role-Based Implementation Guides:
Related Questions:
What are the key changes that took effect on 1 July 2025?
How does the new GPCCMP system simplify chronic disease management for practitioners?
What are the key changes that took effect on 1 July 2025?
The Bottom Line:
From 1 July 2025, Australia's chronic disease management framework underwent significant changes, streamlining processes with the introduction of the GP Chronic Condition Management Plan (GPCCMP). This involves new MBS item numbers, equalised fees for planning and reviews ($156.55 for GPs, $125.30 for PMPs), simplified referral arrangements, and formal recognition of practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers' assistance roles. These items will be included in the Bulk Billing Practice Incentive Program from 1 November 2025.
The Facts:
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From 1 July 2025, the existing MBS items for GP Management Plans (GPMPs) (229, 721, 92024, 92055), Team Care Arrangements (TCAs) (230, 723, 92025, 92056), and their reviews (233, 732, 92028, 92059) ceased and are replaced by a new streamlined GPCCMP
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Eight new MBS item numbers became billable for GPCCMP: 965 (GP face-to-face), 92029 (GP telehealth video), 392 (PMP face-to-face), and 92060 (PMP telehealth video) for plan development; and 967 (GP face-to-face), 92030 (GP telehealth video), 393 (PMP face-to-face), and 92061 (PMP telehealth video) for plan reviews
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The MBS fees for planning and review items are equalised to $156.55 for GPs and $125.30 for Prescribed Medical Practitioners (PMPs)
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The requirement to consult with at least two collaborating providers for a Team Care Arrangement has been removed
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Allied health referrals now use a standard referral letter, consistent with referrals to medical specialists, no longer requiring a structured Medicare form
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The ability for practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers to assist in the preparation of a GPCCMP has been specified in the regulatory arrangements
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Patients registered with MyMedicare are required to access GPCCMP services through their registered practice. Patients not registered with MyMedicare can continue to access these services through their usual GP
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Existing GPMPs and TCAs, along with associated referrals, remain valid until 30 June 2027, allowing a transition period
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From 1 July 2027, a GPCCMP will be required for ongoing access to allied health services and Domiciliary Medication Management Reviews (items 245 and 900)
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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
Sources: Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet; MBS Items for GP Chronic Condition Management Plans – Factsheet; Transition Arrangements for Existing Patients – Factsheet; What Do the Changes Mean for Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers? – Factsheet; MBS Online explanatory note AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6
Links and Resources:
Official Information:
Implementation Support:
Role-Based Implementation Guides:
Related Questions:
What are the new MBS item numbers for GPCCMP preparation and reviews?
Which old MBS item numbers for GPMPs and TCAs are being replaced by the new GPCCMP items?
Why are these changes being made to the chronic disease management framework?
The Bottom Line:
The changes to the chronic disease management framework, transitioning to the GPCCMP, are being made to simplify care planning, reduce administrative burden on practices, and strengthen continuity of care for patients, all stemming from recommendations by the MBS Review Taskforce. The changes also formally recognise the important role of practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers in chronic condition management.
The Facts:
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The changes are a result of a review by the MBS Review Taskforce, informed by the General Practice and Primary Care Clinical Committee
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The General Practice and Primary Care Clinical Committee was established in 2016 to provide broad clinician and consumer expertise
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The MBS Review included a public consultation process from December 2018 to March 2019, with feedback received from a broad range of stakeholders
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Following the MBS Review, ongoing consultation occurred through an Implementation Liaison Group including the Australian Medical Association, Royal Australian College of General Practitioners, Rural Doctors Association, Allied Health Professionals Australia, the Australian Primary Health Care Nurses Association, the National Association of Aboriginal and Torres Strait Islander Health Workers and Practitioners, and other professional associations
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The framework aims to:
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Make care planning easier for practices and patients
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Encourage regular, structured reviews
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Reduce paperwork and streamline referral and claiming processes
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Strengthen continuity of care through the MyMedicare patient registration system
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Formalise arrangements for support provided by practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers
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One of the objectives is to provide patients with greater choice and flexibility in accessing allied health services
Sources: Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet; MBS Items for GP Chronic Condition Management Plans – Factsheet; What Do the Changes Mean for Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers? – Factsheet
Links and Resources:
Related Questions:
How does the new GPCCMP system simplify chronic disease management for practitioners?
What are the patient eligibility criteria for GPCCMPs and how do they compare to the old system?
How does the new GPCCMP system simplify chronic disease management for practitioners?
The Bottom Line:
The GPCCMP system simplifies chronic disease management for practitioners by consolidating the previous two plans (GPMP and TCA) into a single, comprehensive plan. This significantly reduces administrative complexity, eliminates the requirement for multi-provider collaboration during plan development, streamlines allied health referrals to a standard letter format, and formally recognises the assistance provided by practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers.
The Facts:
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The new framework introduces a single GP Chronic Condition Management Plan (GPCCMP) that replaces the existing GP Management Plan (GPMP) and Team Care Arrangement (TCA), meaning your team will move from managing two separate planning processes to a single, streamlined approach
-
The requirement to consult with at least two collaborating providers as part of a Team Care Arrangement has been removed. GPs and Prescribed Medical Practitioners (PMPs) can now refer patients directly to relevant services
-
Referrals to allied health providers will be issued via a standard referral letter, no longer requiring a structured Medicare form, which simplifies the referral process
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The ability for practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers to assist the GP or prescribed medical practitioner to prepare or review a GPCCMP has been specified in the regulatory arrangements for the new items
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The changes aim to simplify, streamline, and modernise the arrangements for health professionals
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Use of referral letters will support the provision of relevant clinical information to allied health professionals
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MyMedicare registration requirements support continuity of care through strengthened usual medical practitioner requirements
Sources: Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet; MBS Items for GP Chronic Condition Management Plans – Factsheet; Referral Arrangements for Allied Health Services – Factsheet; What Do the Changes Mean for Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers? – Factsheet; MBS Online explanatory note AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6
Links and Resources:
Official Information:
Role-Based Implementation Guides:
Related Questions:
How have allied health referral requirements changed under GPCCMP?
Do I still need to consult with two allied health providers before making a referral?
What are the patient eligibility criteria for GPCCMPs and how do they compare to the old system?
The Bottom Line:
Patient eligibility for GPCCMPs remains largely consistent with the old system: any patient with a chronic condition expected to last six months or more, or a terminal illness, is eligible based on clinical judgment. The main difference is the new requirement for MyMedicare registered patients to access GPCCMP services exclusively through their registered practice, enhancing continuity of care.
The Facts:
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A GPCCMP is available to patients with at least one chronic medical condition that has been (or is likely to be) present for at least 6 months, or is terminal
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There is no specific list of eligible conditions. It is up to the GP or Prescribed Medical Practitioner (PMP) to determine, based on their clinical judgment, whether an individual patient with a chronic condition would benefit from a GPCCMP
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Patients registered with MyMedicare are required to access GPCCMP services through their registered practice, while patients not registered with MyMedicare can access these services at any practice but should use their usual GP. These requirements apply to both face-to-face and telehealth items
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The eligibility criteria are the same as under the previous GPMP/TCA system, except that GPCCMPs are not available to patients who are care recipients in a residential aged care facility (though allied health services remain available to RACF patients through multidisciplinary care plans)
Sources: Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet; MBS Items for GP Chronic Condition Management Plans – Factsheet; MBS Online explanatory note AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6
Links and Resources:
Official Information:
Implementation Support:
Cubiko Insights - GPCCMP metrics and forecasting dashboard: Learn how Cubiko can help you identify eligible patients
Related Questions:
Can patients in residential aged care facilities (RACFs) get a GPCCMP?
Does a GPCCMP expire and what are the requirements to maintain patient eligibility for services?
Can patients in residential aged care facilities (RACFs) get a GPCCMP?
The Bottom Line:
No, patients residing in residential aged care facilities (RACFs) are not eligible for GP Chronic Condition Management Plans (GPCCMPs). However, they can still access allied health services through a multidisciplinary care plan.
The Facts:
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GPCCMPs are not available to patients who are care recipients in a residential aged care facility
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Allied health services are available to patients in residential aged care facilities through a multidisciplinary care plan
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet; MBS Online explanatory note AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6
Links and Resources:
Official Information:
Role-Based Implementation Guides:
Related Questions:
What are the patient eligibility criteria for GPCCMPs and how do they compare to the old system?
Do the changes affect multidisciplinary care plan items or other multidisciplinary services available to patients?
Does a GPCCMP expire and what are the requirements to maintain patient eligibility for services?
The Bottom Line:
A GPCCMP itself does not expire; once created, it can be used indefinitely with ongoing reviews. However, to maintain a patient's eligibility for MBS-funded allied health and other services under the plan, it must be reviewed or prepared within an 18-month timeframe. Regular reviews are encouraged, typically every 3 months if clinically appropriate.
The Facts:
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A GPCCMP does not expire under the new framework. Once prepared, it can be used indefinitely with regular reviews
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To maintain access to MBS-funded Allied Health Services, a GPCCMP must have been prepared or reviewed in the previous 18 months
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GPCCMP preparation can be claimed once every 12 months, if clinically appropriate. It is not required that a new plan be prepared each year; existing plans can continue to be reviewed
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GPCCMP reviews can be claimed every 3 months, if clinically appropriate. Reviews can be prepared or conducted earlier if exceptional circumstances apply
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet; What Do the Changes Mean for Allied Health Providers?; Summary of changes to Chronic Disease Management (CDM) Framework; MBS Online explanatory note AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6
Links and Resources:
Official Information:
Implementation Support:
Cubiko Insights - GPCCMP metrics and forecasting dashboard: Use Cubiko to track patients eligible for reviews
Role-Based Implementation Guides:
Related Questions:
What are the timing rules and billing frequencies for GPCCMP creation and reviews?
What reminder systems should I set up for GPCCMP reviews?
What do the GPCCMP changes mean financially for my practice?
The Bottom Line:
The financial impact of the GPCCMP changes on your practice largely depends on your approach to patient reviews. With the new equalised fees for both plan preparation and reviews ($156.55 for GPs, $125.30 for PMPs), and inclusion in the Bulk Billing Practice Incentive Program from 1 November 2025, increasing the frequency of reviews can help maintain or potentially increase your chronic disease management billings, offsetting the previous ability to bill separately for GPMPs and TCAs.
The Facts:
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The MBS fees for planning (new GPCCMP) and review items are equalised. The fee for preparation or review is $156.55 for GPs and $125.30 for Prescribed Medical Practitioners (PMPs)
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Previously, the rebate for a GPMP (items 721, 92024) was $164.35, for TCAs (items 723, 92025) was $130.25, and a review (item 732, 92028) was $82.10
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The impact on annual funding for chronic disease management will depend on the billing approach for each patient
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If no changes are made to the frequency or composition of services (i.e., only billing one item for plan creation), there could be a reduction in the billing. This is largely due to the new item 965 replacing both the old 721 and 723, which previously could both be billed for the same patient in certain circumstances
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Practitioners may be able to increase billings by completing additional reviews, as these now carry an equalised incentive. For example, a change from one new plan and one review to two reviews could result in a slight increase in billings
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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. Consistent with current arrangements, items for the preparation or review of a GPCCMP cannot be co-claimed on the same day as general attendance items
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet; Summary of changes to Chronic Disease Management (CDM) Framework; MBS Online explanatory note AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6
Links and Resources:
Official Information:
Financial Analysis Tools:
Free CDM to CCM billings forecast tool: Model the potential financial impact of the changes under different practice scenarios
Implementation Support:
Cubiko Insights - GPCCMP metrics and forecasting dashboard: Forecast your practice billings based on real data and identify eligible patients
Role-Based Implementation Guides:
Related Questions:
What are the Medicare rebate fees for GPCCMP items and how do they compare to previous GPMP/TCA fees?
Are there bulk billing incentives under GPCCMP and how do they compare to the old system?
What's the best way to set fees for GPCCMP – should we bulk bill or charge privately?
Disclaimer: This FAQ is for general information only and reflects our understanding of upcoming changes to chronic disease management frameworks at the time of publication. For the most accurate and up-to-date guidance, please refer to official sources such as the Department of Health and Aged Care or Medicare. Cubiko is not responsible for any actions taken based on this information.