GPCCMP FAQ - Transitioning Existing Patients & Plans
Categories:
Understanding GPCCMP & Key Changes – Overview of the GP Chronic Care Management Program and what’s new under 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 transition timeline and key steps for moving from existing GPMP/TCA plans to GPCCMPs?
The Bottom Line:
The transition from GPMPs and TCAs to GPCCMPs simplifies chronic disease management with clear steps and timelines. From July 1, 2025, create all new chronic disease management plans as GPCCMPs using the new item numbers. When existing patients need plan reviews after July 1, 2025, transition them to new GPCCMPs. The equalised fees for planning and reviews ($156.55 for GPs, $125.30 for PMPs) support more consistent care, and 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 GPMPs (229, 721, 92024, 92055), team care arrangements (230, 723, 92025, 92056), and their review items (233, 732, 92028, 92059) will cease
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Any new plans put in place from 1 July 2025 will need to meet the requirements of a GPCCMP
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If a patient requires a review of their existing GPMP or TCA after 1 July 2025, they should be transitioned to a new GPCCMP
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Patients with GPMPs and/or TCAs in place prior to 1 July 2025 can continue to access services consistent with those plans during a transition period until 30 June 2027
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The Department of Health, Disability and Ageing have advised:
"While there is no specified minimum time between claiming of the ceased 721/723/732 items and 965 practitioners must ensure that any services provided are clinically relevant."
The full quote is:
“Current chronic disease management patients should have a GP chronic condition management plan prepared (using item 965 or its equivalents) at their first plan/review appointment after 1 July 2025. While there is no specified minimum time between claiming of the ceased 721/723/732 items and 965 practitioners must ensure that any services provided are clinically relevant.
The transition arrangements have been designed so patients don’t need to be recalled early for a new plan to retain their access to allied health services.”
Department of Health, Disability and Ageing
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During this transition period (until 30 June 2027), individual and group allied health services can still be claimed under existing GPMPs and TCAs, and medical practitioners can continue to write referrals under these plans
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Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers will be able to assist the GP or prescribed medical practitioner to prepare or review a GPCCMP
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The fee for the preparation or review of a plan will be $156.55 for GPs and $125.30 for prescribed medical practitioners
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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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Referrals for allied health services written prior to 1 July 2025 will remain valid until all services under that referral have been provided
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From 1 July 2027, a GPCCMP will be required for ongoing access to MBS-funded allied health services and domiciliary medication management reviews (items 245 and 900)
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1-2; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, pages 1-3; Upcoming Changes to Chronic Disease Management MBS Items – Transition Arrangements for Existing Patients – Factsheet, pages 1-2; Upcoming Changes to Chronic Disease Management Framework – Referral Arrangements for Allied Health Services – Factsheet, page 1; Summary of changes to Chronic Disease Management (CDM) Framework, pages 1-2; Department of Health, Disability and Ageing advice; MBS Online explanatory note AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6, MN.12.4
Links and Resources:
Official Information:
Role-Based Implementation Guides:
Billing Support:
What happens to patients with existing GPMPs and TCAs after 1 July 2025?
The Bottom Line:
Patients with existing GPMPs and TCAs as of July 1, 2025, can continue to access care under those plans for a transition period until June 30, 2027. The good news is there's no immediate disruption - they can continue accessing allied health services, practice nurse services (item 10997), and other supports under their existing plans. However, if they require a review of their plan after July 1, 2025, they should be transitioned to a new GPCCMP.
The Facts:
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For patients that have a GPMP and/or TCA in place prior to 1 July 2025 there is no immediate action required
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Patients can continue to access allied health and other services under their existing plans until 30 June 2027
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Patients can continue to access services provided through MBS item 10997 (and its telehealth equivalents 93201 and 93203) under existing GPMPs and TCAs until 30 June 2027
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Individual and group allied health services can be accessed under existing GPMPs and TCAs until 30 June 2027
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Medical practitioners can continue to write referrals under these existing plans until 30 June 2027, but any new referrals written from 1 July 2025 must meet the new referral requirements (letters instead of forms)
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Referrals written prior to 1 July 2025 will continue to be valid until all services under that referral have been provided
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MBS items for reviewing GPMPs and TCAs will cease on 1 July 2025
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If a patient requires a review of their GPMP and/or TCA after 1 July 2025 they should be transitioned to a new GPCCMP at that time
-
The Department of Health, Disability and Ageing have advised:
"While there is no specified minimum time between claiming of the ceased 721/723/732 items and 965 practitioners must ensure that any services provided are clinically relevant."
The full quote is:
“Current chronic disease management patients should have a GP chronic condition management plan prepared (using item 965 or its equivalents) at their first plan/review appointment after 1 July 2025. While there is no specified minimum time between claiming of the ceased 721/723/732 items and 965 practitioners must ensure that any services provided are clinically relevant.
The transition arrangements have been designed so patients don’t need to be recalled early for a new plan to retain their access to allied health services.”
Department of Health, Disability and Ageing
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From 1 July 2027 patients will require a GPCCMP to continue to access allied health and other services
Sources: Upcoming Changes to Chronic Disease Management MBS Items – Transition Arrangements for Existing Patients – Factsheet, pages 1-2; Summary of changes to Chronic Disease Management (CDM) Framework, page 1; 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 1; Department of Health, Disability and Ageing advice; MBS Online explanatory note AN.15.3, AN.15.5, MN.12.4
Links and Resources:
Official Information:
Role-Based Implementation Guides:
When should I transition patients to GPCCMP and what are the billing timing rules?
The Bottom Line:
You should transition patients to a GPCCMP when their existing GPMP or TCA is due for a review after July 1, 2025. For any new patients requiring a chronic disease management plan from that date, it will be a GPCCMP. The practical reality is that the new equalised fees ($156.55 for GPs, $125.30 for PMPs) support more consistent care delivery, with plans available every 12 months and reviews every 3 months if clinically relevant.
The Facts:
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Any new plans put in place from 1 July 2025 will need to meet the requirements of a GPCCMP
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Any new referrals for allied health services should meet the new referral requirements that come into effect on 1 July 2025, regardless of whether the referral is made under a GPMP, TCA or GPCCMP
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MBS items for reviewing GPMPs and TCAs will cease on 1 July 2025 - if a patient requires a review after 1 July 2025 they should be transitioned to a new GPCCMP
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The Department of Health, Disability and Ageing have advised: "While there is no specified minimum time between claiming of the ceased 721/723/732 items and 965 practitioners must ensure that any services provided are clinically relevant"
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Unless exceptional circumstances apply, a GPCCMP can be prepared once every 12 months if clinically relevant; GPCCMP reviews are available every 3 months if clinically relevant
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Plans may be prepared or reviewed earlier if 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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Items for the preparation or review of a GPCCMP cannot be co-claimed on the same day as general attendance items
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The fee for the preparation or review of a plan will be $156.55 for GPs and $125.30 for prescribed medical practitioners
Sources: Summary of changes to Chronic Disease Management (CDM) Framework, page 1; Upcoming Changes to Chronic Disease Management MBS Items – Transition Arrangements for Existing Patients – Factsheet, page 2; Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1-3; MBS Online explanatory note AN.0.47, AN.15.3, AN.15.4, AN.15.5
Links and Resources:
Official Information:
Billing Support:
Role-Based Implementation Guides:
If a patient already has a GPMP, do I start with a new GPCCMP after 1 July, rather than a review?
The Bottom Line:
Yes, if a patient with an existing GPMP or TCA needs a review after July 1, 2025, you should prepare a new GPCCMP for them, as the old review item numbers will no longer be billable.
The Facts:
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MBS items for reviewing GPMPs (233, 732, 92028, 92059) and TCAs will cease on 1 July 2025
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If a patient requires a review of their GPMP and/or TCA after 1 July 2025 they should be transitioned to a new GP chronic condition management plan (GPCCMP)
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The Department of Health, Disability and Ageing have advised: "While there is no specified minimum time between claiming of the ceased 721/723/732 items and 965 practitioners must ensure that any services provided are clinically relevant"
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For patients that have a GPMP and/or TCA in place prior to 1 July 2025 there is no immediate action required
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Patients can continue to access allied health and other services under their existing plans until 30 June 2027
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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 a GPMP or TCA that was put in place prior to 1 July 2025 they should be transitioned to the new arrangements through the preparation of a GPCCMP
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Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers will be able to assist the GP or prescribed medical practitioner to prepare the new GPCCMP
Sources: Upcoming Changes to Chronic Disease Management MBS Items – Transition Arrangements for Existing Patients – Factsheet, pages 1-2; 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, AN.15.3, AN.15.4, MN.12.4
Links and Resources:
Official Information:
Billing Support:
Role-Based Implementation Guides:
What is the process for transitioning a patient from an old plan to a new GPCCMP?
The Bottom Line:
Transitioning a patient from an old GPMP or TCA to a new GPCCMP after July 1, 2025, involves preparing a new GPCCMP following the updated requirements. The good news is that the process has been streamlined - you'll focus on patient-centred goals and outlining care needs without the previous collaboration requirements.
The Facts:
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When a patient requires a review of an existing GPMP or TCA after 1 July 2025, they should be transitioned to the new GPCCMP by preparing a new plan
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Preparing a GPCCMP involves creating a written plan that describes: the patient's chronic condition(s) and associated healthcare needs; health and lifestyle goals developed collaboratively by the patient and the medical practitioner using a shared decision-making approach; actions to be taken by the patient; treatment and services the patient is likely to need; if multidisciplinary care is required, the services the medical practitioner will refer the patient to, including the purposes of those treatments or services; arrangements for reviewing the plan, including a proposed timeframe for review
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The process must also include: recording the patient's consent and agreement to the plan's preparation; offering a copy of the plan to the patient and their carer (if appropriate and consented to by the patient); adding a copy of the plan to the patient's medical records
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The Department of Health, Disability and Ageing have advised:
"While there is no specified minimum time between claiming of the ceased 721/723/732 items and 965 practitioners must ensure that any services provided are clinically relevant."
The full quote is:
“Current chronic disease management patients should have a GP chronic condition management plan prepared (using item 965 or its equivalents) at their first plan/review appointment after 1 July 2025. While there is no specified minimum time between claiming of the ceased 721/723/732 items and 965 practitioners must ensure that any services provided are clinically relevant.
The transition arrangements have been designed so patients don’t need to be recalled early for a new plan to retain their access to allied health services.”
Department of Health, Disability and Ageing
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If referring to a multidisciplinary team member, the GP or PMP must obtain the patient's consent to share relevant information and provide relevant parts of the plan in addition to the referral
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Allied health providers do not need to confirm acceptance of the referral or provide input into plan preparation, but they are still required to send written reports back to the GP after certain services (e.g., the first service)
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Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers will be able to assist the GP or prescribed medical practitioner to prepare or review a GPCCMP
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 3-4; Upcoming Changes to Chronic Disease Management MBS Items – Transition Arrangements for Existing Patients – Factsheet, pages 1-2; Summary of changes to Chronic Disease Management (CDM) Framework, page 1; Upcoming Changes to Chronic Disease Management Framework – Referral Arrangements for Allied Health Services – Factsheet, page 1; MBS Online explanatory note AN.0.47, AN.15.3, AN.15.4, AN.15.6, MN.12.4
Links and Resources:
Official Information:
Billing Support:
Role-Based Implementation Guides:
Can patients continue using existing allied health referrals after 1 July 2025?
The Bottom Line:
Yes, patients can absolutely continue using referrals written before July 1, 2025 until all services under that referral have been provided. However, any new referrals from July 2025 must meet the new referral requirements - this means using referral letters instead of forms, consistent with how you refer to medical specialists. You'll find this actually streamlines the process while maintaining the same service access for patients.
The Facts:
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Referrals for allied health services written prior to 1 July 2025 will remain valid until all services under the referral have been provided
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Any new referrals for allied health services should meet the new referral requirements that come into effect on 1 July 2025, regardless of whether the referral is made under a GPMP, TCA or GPCCMP
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Individual and group allied health services can be accessed under existing GPMPs and TCAs until 30 June 2027
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Medical practitioners can continue to write referrals under existing plans until 30 June 2027, but any new referrals written from 1 July 2025 must meet the new referral requirements (letters instead of forms)
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From 1 July 2025, referral forms will no longer be used for referrals to allied health services - referral letters will be used, consistent with the referral process for medical specialists
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Unless otherwise specified by the referring medical practitioner, referrals to allied health services for patients with a chronic condition will be valid for 18 months
Sources: Summary of changes to Chronic Disease Management (CDM) Framework, page 1; Upcoming Changes to Chronic Disease Management MBS Items – Transition Arrangements for Existing Patients – Factsheet, pages 1-2; Upcoming Changes to Chronic Disease Management Framework – Referral Arrangements for Allied Health Services – Factsheet, page 1; MBS Online explanatory note AN.15.3, AN.15.5, AN.15.6
Links and Resources:
Official Information:
Role-Based Implementation Guides:
Can patients continue accessing practice nurse services (item 10997) with their old plans during the transition?
The Bottom Line:
Yes, patients with existing GPMPs and TCAs can continue accessing practice nurse services through item 10997 (and its telehealth equivalents) under those plans until 30 June 2027. This ensures continuity for these important services during the transition period. What's particularly encouraging is that practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers will be formally recognised as being able to assist with GPCCMP preparation and reviews under the new framework.
The Facts:
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Patients can continue to access services provided through MBS item 10997 (and its telehealth equivalents 93201 and 93203) under existing GPMPs and TCAs until 30 June 2027
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From 1 July 2027, a GPCCMP will be required for ongoing access to MBS-funded allied health and related services
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Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers will be able to assist the GP or prescribed medical practitioner to prepare or review a GPCCMP under the new framework
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The nature of the services that can be provided using items 10997, 93201, 93203 are not changing as part of these reforms
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To remain eligible for these services, patients (other than those covered by the transition arrangements) will have to have had their GPCCMP prepared or reviewed in the previous 18 months
Sources: Upcoming Changes to Chronic Disease Management MBS Items – Transition Arrangements for Existing Patients – Factsheet, page 1; Summary of changes to Chronic Disease Management (CDM) Framework, page 1; Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, pages 1-2; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 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, pages 1-2; MBS Online explanatory note AN.15.3, AN.15.5, MN.12.4
Links and Resources:
Official Information:
Role-Based Implementation Guides:
How do service entitlements work when transitioning from old plans to GPCCMPs, especially if a patient has already used their allied health visits under a previous plan?
The Bottom Line:
Patients can access up to 5 individual allied health services per calendar year under a GPCCMP (10 services for patients of Aboriginal or Torres Strait Islander descent), with entitlements resetting each January 1st regardless of previous plan usage. What's helpful to know is that unused services don't roll over between years - patients start fresh each calendar year with their full entitlement.
The Facts:
The MBS factsheets don't provide specific information about service entitlement transitions between old and new plans.
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Patients can access up to 5 individual allied health services per calendar year where these services are consistent with their GPCCMP
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For patients of Aboriginal or Torres Strait Islander descent, this entitlement is up to 10 services per calendar year
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Patients' eligibility for services is reset on 1 January every year automatically - they are not required to review their plan to enable services or otherwise reset the count, provided patients continue to meet the eligibility requirements for the service
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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
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Patients with GPMPs and/or TCAs in place prior to 1 July 2025 can continue to access individual and group allied health services under those existing plans until 30 June 2027
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To continue to access allied health services beyond this transition period (or for any new plan after July 1, 2025), a GPCCMP must have been prepared or reviewed in the previous 18 months
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The nature of the individual and group allied health services that can be provided under the chronic condition management arrangements are not changing as part of these reforms, but the item descriptors have changed due to the removal of GPMPs and TCAs and commencement of GPCCMPs
Sources: Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans – Factsheet, page 2; Upcoming Changes to Chronic Disease Management Framework – Overview – Factsheet, page 2; Upcoming Changes to Chronic Disease Management MBS Items – Transition Arrangements for Existing Patients – Factsheet, page 1; Summary of changes to Chronic Disease Management (CDM) Framework, page 2; Upcoming Changes to Chronic Disease Management MBS Items –What Do the Changes Mean for Allied Health Providers? – Factsheet, pages 1-2; MBS Online explanatory note AN.15.3, AN.15.5, AN.15.6, MN.11.1
Links and Resources:
Official Support:
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.