Since 1 July, the Department of Health Disability and Ageing have implemented major updates to the Medicare Benefits Schedule (MBS) for chronic disease management, based on the MBS Review Taskforce recommendations. The new Chronic Condition Management (GPCCMP) model aims to simplify care planning, improve access, and enhance continuity of care for patients with long-term conditions.
Key Changes:
- New single care plan: A single GP Chronic Condition Management Plan replaces existing GPMP and TCA items
- Referral process update: Referral letters will replace current allied health referral forms
- Fee standardisation: GPs will receive $156.55 for both plan preparation and reviews
- Access via MyMedicare: Registered patients must use their registered practice. Non-registered patients can continue with their usual GP
- Simplified team requirements: Multidisciplinary team requirements removed; except for existing team care items (e.g., 231, 232, 729, 731)
- Expanded support roles: PNs, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers can assist with plans
- Access to allied health: requires a plan prepared or reviewed in the last 18 months
Plan frequency:
- New plans can be prepared annually
- Reviews are allowed every three months
- Annual renewal of plans is not required if reviewed appropriately
Transition Period:
- Existing care plans remain valid until 30 June 2027 during a two-year transition phase
- Upcoming Changes to Chronic Disease Management MBS Items – Overview
- Upcoming Changes to Chronic Disease Management MBS Items – Transition Arrangements for Existing Patients
- Upcoming Changes to Chronic Disease Management Framework – Referral Arrangements for Allied Health Services
- Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans
- Upcoming Changes to Chronic Disease Management Framework – Allied Health Providers
- Upcoming Changes to Chronic Disease Management Framework – Practice Nurse, Aboriginal Health Workers and Aboriginal and Torres Strait Islander Health Practitioners
- Standard Words – CCM Changes and Implications for MyMedicare Registration
Since 1 July, GPCCMPs replaced previous referral and care planning processes. While MBS allied health items remain unchanged, referral requirements are now simpler:
- GPs don’t need to specify the number of allied health sessions (but can if they choose)
- Named providers are no longer required on referrals
- Team Care Arrangements (TCAs) are no longer needed
Tips for Allied Health Providers:
- Discuss with patients how many of their five annual MBS services they wish to use with your service
- If they have private health insurance, consider using it first to preserve Medicare sessions
- Contact the GP to confirm services in the care plan and coordinate care (e.g. case conferencing or diabetes group sessions)
- Ask patients to check their Medicare claims via the myGov app
- Use HPOS or MBS Online to confirm eligibility and item usage
- Access My Health Record to view care plans, history, and care team members
Western Sydney CCM QI Toolkit
The CCM QI Toolkit helps general practices improve chronic condition management through structured, person-centred, and proactive care. It aligns with the new CCM MBS items and Strengthening Medicare reforms from 1 July.
Key Features:
- Practical, flexible activities tailored to your practice’s needs
- Designed for QI
Get Started:
Activities can be completed in any order however we recommend starting with Module 1 to assess your practices readiness.
Explore individual modules and activities below.
- Activity 2.1: Reminders, Registration and Flagging
- Activity 2.1.1: Management Registration via HPOS
- Activity 2.1.2: Best Practice CCM MyMedicare Registration and Flagging
- Activity 2.1.3: Best Practice – My Health Record MyMedicare Registration
- Activity 2.1.4: Medical Director MyMedicare Registration and Flagging
- Activity 2.1.5: Medical Director – My Health Record MyMedicare Registration
- Activity 2.2: Scripts, Phone, SMS, Email and Website
- Activity 2.3: GoShare Patient Engagement Platform
- Activity 2.4: Check the number of allied health service via Medicare App
- Activity 3.1: MyMedicare Patients
- Activity 3.2: Patients not Registered with MyMedicare
- Activity 3.3: All CCM Patients due for a Care Plan and Reviews
- Activity 3.4: Patients with a Chronic Condition Eligible for a Care Plan Review
- Activity 3.5: Patients with a Risk of Hospitalisation Eligible for a Care Plan Review
- Activity 3.6: Filter by Assign Provider
- Activity 3.7: Create a Prompt to Display in Topbar
- 5.1: Quality Improvement Documentation
- 5.2: PDSA Team Awareness Desire and Readiness
- 5.3: PDSA Identifying Active Patients Linking to MyMedicare Program
- 5.4: PDSA CCM and MyMedicare
- 5.5: PDSA Reducing Missed Appointments for Care Plan Reviews
- 5.6: Measuring Outcomes Audit Worksheet
- 5.7: Group Reflection After Completing Activities
- 5.8: Useful Contacts
- 5.9: MBS Quick Guide July 2025
- CCM MBS Quick Guide July 2025
- RACGP – CCM webpage
- RACGP CDM – Summary of Changes
- Best Practice (BP – Spectra) Premier
- BP CCM Quick Reference Guide
- BP Printable Foldout: CCM Changes
- BP CCM eLearning
- Medical Director (MD – 4.0 & above) – Clinical updates
- Cubiko – GPCCMP webpage
- Cubiko CCM Resource Pack – Poster, timeline, patient handout, flyer, and blog printout on upcoming changes
- Cubiko Billing Cheat Sheet
- Cubiko Team roles and workflows
- Register your practice for MyMedicare (participation is voluntary for both practices and patients)
- Maintain your Organisation Register in HPOS. Ensure your Organisation Site Record and accreditation details are correct, link all providers (GPs, nurses, Aboriginal Health Workers, etc.) from their start date, link patients to their preferred GP, and keep provider records updated when staff join or leave
- Enable HPOS email notifications and understand how to manage them
- Communicate with patients about MyMedicare registration. If your practice is their usual provider for ongoing care (such as chronic condition management), encourage them to register with you. If they prefer another practice, support their registration there instead. Always obtain informed consent. Patients can also register via the myGov app
- Check registration details if MyMedicare-related claim errors occur. The patient must be registered with the specific location where the claim is submitted
MyMedicare-linked MBS items and incentives include:
- GP Chronic Condition Management Plans
- General Practice in Aged Care Incentive
- Level C and D telephone consultations
- Triple Bulk Billing Incentives for longer telehealth (Levels C, D, E) for eligible registered patients
Note: Not all claim rejections are due to MyMedicare. Co-claiming rules and existing MBS requirements still apply.
For more information, visit MBS Online or refer to Explanatory Notes AN.15.3 and AN.0.47.
How Can We Support Your Practice?
The PCTI team are to help your practice prepare for and implement the CCM MBS reforms. Whether you’re just getting started or ready to optimise your workflows, we can provide hands-on support with:
- MyMedicare registration for your practice and providers
- Identifying eligible patients for care planning and MyMedicare
- Optimising MBS claiming through data reviews and tailored strategies
- Embedding QI tools into workflows: patient engagement, team training, and system improvements
Need More Information?
If you’d like support with the CCM Toolkit, MyMedicare registration, or implementation strategies, contact your Primary Care Delivery Officer or email our Virtual Support team at support@wentwest.com.au
Information is correct as of 11 June 2025.