MyMedicare Chronic Condition Management

MyMedicare Chronic Condition Management (CCM)

The new Chronic Condition Management (CCM) items commenced from 1 July 2025, replacing the current GP Management Plans (GPMPs) and Team Care Arrangements (TCAs).

The CCM changes introduced under MyMedicare aim to improve access to high-quality, continuous, and person-centred care for people living with long-term health conditions. These changes streamline and strengthen chronic condition care planning by aligning services with MyMedicare registration and simplifying the model for patients, providers, and practices.

Helpful links

Introducing MyMedicare

Registering for MyMedicare

Overview of Chronic Condition Management changes

These reforms were developed by the Department of Health, Disability and Ageing in response to:

Recommendations from the Strengthening Medicare Taskforce.
Evidence and feedback from healthcare providers and peak bodies.

Key transition points:

A new, single GP Chronic Condition Management Plan will replace GPMPs and TCAs.
Patients must have a chronic medical condition (present for or likely to be present for six months or more, or terminal) to be eligible.
Only patients registered through MyMedicare can access the new planning and review items from their registered practice.
Equalised MBS fees will apply for plan development and review to support continuity of care.
Patients with a GP CCM plans will be able to access individual allied health services, and for patients with type 2 diabetes only, group allied health services.
Patients with existing plans may continue to access current items during the two year transition period.
When billing any new CCM plans or undertaking reviews of a plan, use the MBS item numbers for an initial GP CCM Plan [965, 392, 29029, 29060]. This is necessary as GP CCM Plan Review item numbers are not able to be claimed unless a new CCM Plan has been billed.

Benefits of registering with MyMedicare

Strengthens the patient–practice relationship by formally registering patients and reinforcing your practice as their regular healthcare provider.

Provides access to new and upcoming MBS-funded items, including longer telehealth consults for registered patients, the already live GPACI program, the Bulk Billing Practice Incentive Program (BBPIP) from 1 November 2025 and the Better Access Mental Health care plans from 1 November 2025.

Aligning with national primary care reforms, positioning your practice within evolving models of care and helping you stay ahead of changes in policy and funding.

Eligibility Criteria and Registration

Patients must have a chronic condition and be registered with a practice through MyMedicare.

To be eligible for the new GP Chronic Condition Management Plan (GPCCMP), a patient must meet one of the following criteria:

Have one or more chronic medical conditions that have been, or are likely to be, present for six months or longer, or
Have a terminal medical condition.

This eligibility aligns with the current definition used for GP Management Plans (GPMPs), ensuring continuity in identifying patients who would benefit from structured, ongoing care planning and coordination. The plan is intended to support patients with complex, long-term health needs through a comprehensive and consistent care approach.

Transition Arrangements

Patients who have an active GPMP and/or TCA in place before this date can continue to use these plans until 30 June 2027.

During this transition period, GPs can still claim the existing items for ongoing care, and patients will remain eligible for associated services, such as allied health referrals.

After 1 July 2027, only the GPCCMP will be recognised for claiming relevant MBS items, and all new or ongoing care planning will need to occur under this new framework. This approach is designed to ensure continuity of care while allowing practices and patients time to adjust to the updated chronic disease management model.

CCM Tools and Resources

MBS Online Fact Sheets

Find a series of factsheet released by MBS.

MBS - Note AN.01.47

Sets out the requirements for developing and reviewing GP chronic condition management plans.

CCM Transition Arrangements for Existing Patients

Information from the Department of Health, Disability and Ageing
MBS table with new item number:

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

Need support?

For support, please contact the CCQ Primary Care Coordinator Team at 
pracsupport@c2coast.org.au.

Email us

MyMedicare Help Desk - select option 2

Call 132 150