GPCCMP FAQ - GPCCMP Plan Creation & Reviews
Categories:
Understanding GPCCMP & Key Changes – Overview of the GP Chronic Care Management Program and what’s new under GPCCMP.
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.
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 are the timing rules and billing frequencies for GPCCMP creation and reviews?
The Bottom Line:
The new GPCCMP framework simplifies billing frequency, maintaining a 12-month cycle for new plans and a flexible 3-month cycle for reviews. This encourages more regular and structured patient engagement, ensuring ongoing care for chronic conditions, with equalised fees ($156.55 for GPs, $125.30 for PMPs) and inclusion in the Bulk Billing Practice Incentive Program from 1 November 2025.
The Facts:
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A GPCCMP can be prepared once every 12 months, if clinically relevant, unless exceptional circumstances apply
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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 conducted once every 3 months, if clinically relevant, unless exceptional circumstances apply
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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 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
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The MBS fee to prepare a GPCCMP is $156.55 for GPs and $125.30 for PMPs
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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, pages 1, 2, 3; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 2; MBS Online explanatory note AN.0.47; MBS Online explanatory note AN.15.4
Links and Resources:
Billing Support:
Role-Based Implementation Guides:
Who is eligible for a GPCCMP?
The Bottom Line:
GPCCMPs are available for patients with chronic medical conditions who would benefit from structured care, with broad eligibility based on clinical judgment rather than specific condition lists. The key requirement is that conditions must be present for at least 6 months or be terminal, with some important exclusions for residential aged care patients.
The Facts:
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GPCCMPs are for patients with one or more chronic medical conditions who would benefit from a structured approach to their care
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A chronic medical condition must have been (or is likely to be) present for at least 6 months or is terminal
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There is no list of eligible conditions - it is up to the GP or PMP's clinical judgment to determine whether an individual patient with a chronic condition would benefit from a GPCCMP
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GPCCMPs are not available to patients who are care recipients in a residential aged care facility - allied health services are available to these patients through a multidisciplinary care plan
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For face-to-face items only, patients can be an in-patient of a private hospital - patients that are public in-patients of a hospital are not eligible for these services
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Patients registered with MyMedicare must access GPCCMP items through the practice where they are enrolled; patients who are not registered must access GPCCMP items through their usual GP
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, page 3; MBS Online explanatory note AN.0.47
Links and Resources:
What specific documentation and components are required in a GPCCMP?
The Bottom Line:
A GPCCMP is designed to be a clear, patient-centred plan that requires specific documentation of the patient's condition, shared goals, actions, and planned treatments, including referrals. Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers are now formally able to assist with preparation and reviews, streamlining the process while maintaining comprehensive care coordination.
The Facts:
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Preparing a GPCCMP is defined as preparing a written plan which describes:
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The patient's chronic condition(s) and associated health care needs
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Health and lifestyle goals developed by the patient and medical practitioner using a shared decision-making approach
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Actions to be taken by the patient
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Treatment and services the patient is likely to need
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If the patient would benefit from multidisciplinary care, the services that the medical practitioner will refer the patient to (including the purposes of those treatments or services)
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Arrangements to review the plan, including the proposed timeframe for review
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The process of developing and finalising a GPCCMP must include:
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Recording the patient's consent and agreement to the preparation of the plan
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Offering a copy of the plan to the patient and their carer (if any, and if appropriate and the patient agrees)
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Adding a copy of the plan to the patient's medical records
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A practice nurse, Aboriginal and Torres Strait Islander Health Practitioner or Aboriginal Health Worker may assist with the development or review of a plan
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 3-4; MBS Online explanatory note AN.15.4
Links and Resources:
Do I need to get a patient's consent before creating or sharing a GPCCMP?
The Bottom Line:
Yes, obtaining patient consent is a crucial step for both creating and sharing a GPCCMP. This ensures that patients are active participants in their care planning and that their information is handled respectfully and securely throughout the process.
The Facts:
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The process of developing and finalising a GPCCMP must include recording the patient's consent and agreement to the preparation of the plan
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If the patient is to be referred to a member of a multidisciplinary team, the GP or PMP must obtain the patient's consent to sharing relevant information, including relevant parts of the plan, with the multidisciplinary team
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The process of reviewing a GPCCMP must also include recording the patient's consent and agreement to the updates made to the plan
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 4, 5
Links and Resources:
Should GPCCMPs be uploaded to My Health Record?
The Bottom Line:
Yes, it's strongly encouraged to upload GPCCMPs to My Health Record, provided you have the patient's consent. This helps ensure vital care information is accessible across different healthcare providers, supporting better continuity of care for your patients, though upload is not a requirement for MBS claiming.
The Facts:
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Subject to the patient's consent, GPs and PMPs are encouraged to upload the GPCCMP to My Health Record
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Upload is not a requirement of the MBS item, so it is not essential that the plan be uploaded prior to submitting an MBS claim
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, page 3; MBS Online explanatory note AN.0.47
Links and Resources:
What allied health services can patients access with a GPCCMP and how many visits per year are covered?
The Bottom Line:
Patients with a GPCCMP can access a similar range of MBS-supported allied health and nurse services as before, including up to 5 individual allied health services annually (10 for Aboriginal or Torres Strait Islander patients). For Type 2 Diabetes patients, additional group services are also available, supporting comprehensive multidisciplinary care.
The Facts:
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Patients can access the following MBS-supported services where they are consistent with their GPCCMP:
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Up to 5 individual allied health services per calendar year (with 10 services available for patients of Aboriginal or Torres Strait Islander descent)
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Up to 5 services provided on behalf of a medical practitioner by a practice nurse or Aboriginal and Torres Strait Islander Health Practitioner (Fee: $14.00 Benefit: 100% = $14.00 for item 10997)
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For patients with type 2 diabetes, an assessment of their suitability for group dietetics, diabetes education or exercise physiology services, and if suitable, up to 8 group services for the management of diabetes per calendar year
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Aboriginal and Torres Strait Islander health services using MBS items 10950, 81300, 93000, 93013, 93048 and 93061
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Where multidisciplinary care is required, patients will be able to access the same range of services currently available through GP management plans and team care arrangements
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Patients must have had a GPCCMP prepared or reviewed in the previous 18 months to continue to access allied health and other services under the plan
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 2; Upcoming Changes to the Chronic Disease Management Framework – What Do the Changes Mean Do Practice Nurses, Aboriginal and Torress Strait Islander Health Practitioners and Aboriginal Health Workers? – Factsheet, page 2; MBS Online explanatory note AN.15.4; MBS Online explanatory note AN.15.6, MN.12.4
Links and Resources:
Role-Based Implementation Guides:
Can the 5 allied health visits be spread over 12 or 18 months, or is it calendar year based?
The Bottom Line:
The 5 individual allied health services (or 10 for Aboriginal or Torres Strait Islander patients) are allocated on a calendar year basis. Patient eligibility resets automatically on 1 January each year, and unused services do not carry over, making it important to plan service usage effectively within each calendar year.
The Facts:
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Patients can access up to 5 individual allied health services per calendar year (with 10 services for patients of Aboriginal or Torres Strait Islander descent)
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For patients with type 2 diabetes, up to 8 group services for diabetes management are provided per calendar year
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Patient eligibility is reset on 1 January every year automatically - you are not required to review their plan to enable services or otherwise reset the count
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Unused services do not rollover - patients are eligible for up to 5 services per calendar year regardless of any prior claiming patterns
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, page 2; MBS Online explanatory note AN.0.47; MBS Online explanatory note MN.12.4
Links and Resources:
Role-Based Implementation Guides:
Can I create a GPCCMP for patients who only need GP care without allied health referrals?
The Bottom Line:
Yes, absolutely. The GPCCMP is designed to support a structured approach to care whether or not multidisciplinary allied health services are required. If a patient can benefit from a GP-led chronic condition management plan, it is clinically appropriate to create one, with the plan being patient-centred and able to identify services supported through various funding mechanisms.
The Facts:
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Patients will be eligible for the plan if their condition is managed by their GP or prescribed medical practitioner, whether or not multidisciplinary care is required
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A GPCCMP is for patients with one or more chronic medical conditions who would benefit from a structured approach to their care
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The plan is intended to be a patient-centred plan - while there are a range of MBS-supported services available for patients with a GPCCMP, services that are supported through other funding mechanisms can also be identified in the plan
Sources: Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 2; Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 3, 4
Links and Resources:
Role-Based Implementation Guides:
Can I include social prescribing in my patient's GPCCMP?
The Bottom Line:
Yes, you can include social prescribing and other non-MBS services in a GPCCMP. The plan is designed to be comprehensive and patient-centred, accommodating various funding mechanisms beyond Medicare to support holistic chronic condition management.
The Facts:
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There is nothing that precludes the inclusion of activities or services that are not covered by MBS funding arrangements, such as social prescribing
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The GPCCMP is intended to set out the agreed actions and services that would be beneficial to the patient in managing their chronic condition
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It is important that patients are aware when services that are not supported by the MBS are included in their plan
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While there are a range of MBS-supported services available for patients with a GPCCMP, services that are supported through other funding mechanisms can also be identified in the plan
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, page 4; MBS Online explanatory note AN.0.47
Links and Resources:
Role-Based Implementation Guides:
How do I handle GPCCMPs for patients with complex multiple chronic conditions?
The Bottom Line:
The GPCCMP is designed to effectively manage patients with one or more chronic conditions, including those with complex needs. The plan is patient-centred and comprehensive, allowing for identification of a wide range of treatments and services, whether MBS-funded or otherwise, and enabling referrals to a multidisciplinary team as needed without the previous requirement for collaboration with at least two providers.
The Facts:
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GPCCMPs are for patients with one or more chronic medical conditions who would benefit from a structured approach to their care
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The written plan must describe the patient's chronic condition(s) and associated health care needs
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The plan is intended to be a patient-centred plan, and while it supports MBS-funded services, services supported through other funding mechanisms can also be identified in the plan
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If the patient would benefit from multidisciplinary care, the plan should identify the services the medical practitioner will refer the patient to. A member of the multidisciplinary team is a person who provides treatment or service to the patient and provides a different kind of treatment or service than each other member
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The requirements for a GPCCMP have been streamlined compared to GPMPs and TCAs - consultation with at least two collaborating providers is no longer required
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 3, 4, 5
Links and Resources:
Role-Based Implementation Guides:
Can I do GPCCMPs or reviews via telehealth or phone?
The Bottom Line:
You can provide GPCCMP preparation and review services via telehealth (video), as specific MBS items have been introduced for these modalities (92029, 92030, 92060, 92061). This provides flexibility for both practitioners and patients in managing chronic conditions, though there are no dedicated phone-only GPCCMP items available.
The Facts:
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GPCCMPs can be prepared and reviewed by GPs and prescribed medical practitioners either face to face, or via video
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New MBS item numbers are available for both face-to-face and telehealth (video) services for developing a GPCCMP (965, 392 face-to-face; 92029, 92060 video) and reviewing a GPCCMP (967, 393 face-to-face; 92030, 92061 video)
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Telehealth items are not subject to the established clinical relationship rule that applies to most general practice telehealth items - instead, they are subject to the same MyMedicare and usual medical practitioner requirements as the face-to-face items
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Consistent with general telehealth rules, telehealth items cannot be used when the patient is an admitted patient of a hospital
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GPCCMP services can be provided to a patient in a hospital, but only by medical practitioners who are not employed by the proprietor of a hospital that is not a private hospital, or is employed by such proprietor and provides the service otherwise than in the course of employment
Sources: Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 1; Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1, 2; Summary of changes to Chronic Disease Management (CDM) Framework, page 2; MBS Online explanatory note AN.0.47
Links and Resources:
Billing Support:
Role-Based Implementation Guides:
Can I do a GPCCMP review for a patient who had their GPCCMP created elsewhere?
The Bottom Line:
We have asked this question and currently awaiting a reply.
The Facts:
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Patients registered with MyMedicare must access GPCCMP items through the practice where they are enrolled. These requirements apply to both face-to-face and telehealth items
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Patients who are not registered with MyMedicare may access GPCCMP services through their usual GP
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"Usual medical practitioner" is defined in the Regulations as a general practitioner or prescribed medical practitioner:
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Who has provided the majority of services to the person in the past 12 months; or
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Who is likely to provide the majority of services to the person in the following 12 months; or
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Located at a medical practice that has provided the majority of services to the person in the past 12 months or is likely to provide the majority of services in the next 12 months
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The new MBS items to review a GPCCMP should only be used to review an existing GPCCMP - if a patient requires a review of their GPMP or TCA that was put in place prior to 1 July 2025, they should be transitioned to the new GPCCMP at that time through the preparation of a new GPCCMP
Sources: Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 2; Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 2, 4; Upcoming Changes to Chronic Disease Management MBS Items – Transition Arrangements for Existing Patients – Factsheet, page 2; Summary of changes to Chronic Disease Management (CDM) Framework, page 1; MBS Online explanatory note AN.0.47
Links and Resources:
Role-Based Implementation Guides:
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.