Chronic Condition Management: MBS Items Reform

From 1 July 2025 the Department of Health and Aged Care has announced major changes to the MBS framework for chronic disease management in primary care will come into effect. These changes implement the recommendations of the MBS Review Taskforce.  

This new Chronic Condition Management model simplifies how care plans are created and reviewed, improving access and continuity for patients managing long-term conditions. 

Key updates include: 

  • A single GP chronic condition management plan replaces current GPMP and TCA items
  • Referral letters will replace existing allied health referral forms
  • Equalised fees for preparation and review of plans ($156.55 for GPs)
  • MyMedicare-registered patients must access GPCCMP services through their registered practice; non-registered patients may use their usual GP
  • Multidisciplinary team requirements have been simplified – the previous requirement to collaborate with two providers has been removed. Multidisciplinary care plan items (e.g., 231, 232, 729, 731) are not affected by this reform
  • Practice nurses, Aboriginal and Torres Strait Islander Health Practitioners, and Aboriginal Health Workers can now assist in preparing or reviewing a plan
  • Patients must have had a plan prepared or reviewed within the last 18 months to access MBS-funded allied health services
  • A plan can be prepared once every 12 months, and reviews can occur every 3 months. A new plan each year is not required—existing plans can be reviewed

Current plans remain valid during a 2-year transition period until 30 June 2027. 

These changes aim to streamline care and support better outcomes for patients with chronic conditions. 

Further information is provided in the Factsheet ( PDF and Word versions) below.

Upcoming Changes to Chronic Disease Management MBS Items – Overview (Last updated: 22 May 2025)

Upcoming Changes to Chronic Disease Management MBS Items – Transition Arrangements for Existing Patients (Last updated: 22 May 2025)

Upcoming Changes to Chronic Disease Management Framework – Referral Arrangements for Allied Health Services (Last updated: 22 May 2025)

Upcoming Changes to Chronic Disease Management Framework – MBS Items for GP Chronic Condition Management Plans (Last updated: 22 May 2025)

Upcoming Changes to Chronic Disease Management Framework – Allied Health Providers (Last updated: 6 June 2025)

Upcoming Changes to Chronic Disease Management Framework – Practice Nurse, Aboriginal Health Workers and Aboriginal and Torres Strait Islander Health Practitioners (Last updated: 6 June 2025)

Standard Words – CCM Changes and Implications for MyMedicare Registration

Western Sydney Chronic Condition Management Toolkit

The Chronic Conditions Management (CCM) QI Toolkit provides a practical guide to help general practices implement continuous Quality Improvement (QI) activities for managing chronic conditions.

It supports primary care teams in delivering structured, proactive, and person-centred care — enhancing continuity, improving patient outcomes, and increasing efficiency. The toolkit aligns with the revised Chronic Condition Management (CCM) MBS items and the Strengthening Medicare reforms, coming into effect from 1 July 2025.

Navigating this Toolkit

This toolkit includes flexible, practical activities designed to meet your practice’s unique needs. Activities are not intended to be completed in sequence — you can start where it makes the most sense for your team.

We recommend starting with Module 1 – Practice Readiness to assess your current state and prepare for the upcoming MBS changes.

How to Use

Top tips for MyMedicare for general practices

  1. Register your practice for MyMedicare*

  2. MyMedicare practices should setup and maintain their Organisation Register including:

    1. Ensure your Organisation Site Record details are correct (see Organisation Register – Health Professional Education Resources).

    2. Make sure providers are linked from the date the Organisation Site Record was created or the day they commenced working from the practice (this includes GPs, Registrars, Nurse Practitioners, Practice Nurses, Aboriginal Health Workers and Practitioners).

    3. Link your patients to their preferred GP in the Organisation Site Record.

    4. Keep your Organisation Register up to date when providers change at your practice (when a provider leaves or a new provider starts at your practice).

    5. Keep your accreditation up to date – check your accreditation record and ensure your accreditation details are added correctly (see page 8 – ORGREGM06 – Amend your Organisation Site Record through HPOS).

  3. Switch on your HPOS notifications by email, and understand HPOS notifications

  4. Communicate with your patients about MyMedicare registration*.

    1. If you are the patient’s usual practice they wish to attend for ongoing care (such as GP Chronic Conditions Management care), encourage patients to register for MyMedicare with your practice.

    2. If a patient prefers to visit another general practice for ongoing care, do not register them for MyMedicare at your practice. Encourage them to register for MyMedicare and attend their preferred practice- particularly for care that is ongoing care (such as GP Chronic Conditions Management Items).

*MyMedicare Registration is voluntary for both patients and practices. Patients can self-register using the MyGov app. Practices must always gain informed consent from patients for MyMedicare registration.

  1. If you are receiving a MyMedicare-related error code when processing claims, check that the patient is registered for MyMedicare with your practice. Remember, if you have more than one practice location, the patient needs to be registered at the location that the claim is being made.

MBS Items and Incentives linked with a MyMedicare conditional rule^ include:

^It is important to remember that not all claim rejections are related to MyMedicare. Co-claiming restrictions may apply. There are also long-standing MBS rules that apply to GP chronic condition management items that may result in a claim being rejected.

For further information on GP chronic condition management plans please see:

·       MBS Online – Upcoming changes to the MBS Chronic Disease Management Framework
·       MBS Online Explanatory Notes including AN.15.3 and AN.0.47.

 

How Can We Support Your Practice?

Our Primary Care Development Team is here to help your practice prepare for and implement the Chronic Condition Management (CCM) MBS reforms. Whether you’re just getting started or ready to optimise your workflows, we can provide hands-on support with:

  • Registration of your practice and providers for MyMedicare
  • Identify patients with chronic conditions who may benefit from structured care planning and MyMedicare registration
  • Optimising MBS claiming through data reviews and tailored improvement strategies
  • Embedding toolkit activities into your practice – including QI planning, patient engagement, team training and system workflows

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.