GP Chronic Condition Management Plan(GPCCMP)

Why this matters for your practice

The GP chronic condition management plan replaced the GP Management Plan and the Team Care Arrangement on 1 July 2025, and the content of both the plan and the review is now defined word for word in the Health Insurance (General Medical Services Table) Regulations 2021. If your documentation does not match those words, the claim is exposed. This is not theoretical: through 2025 the Professional Services Review's dominant trigger was non-individualised chronic disease management plans, and one GP agreed to repay $595,000, accept a 12-month disqualification from chronic disease management items and be reprimanded by the Director. Legacy care plan templates carried into the new item numbers compound that risk. The frequency rules are the other thing a compliance review checks first: one plan every 12 months, one review every 3 months, and a new plan at least 3 months after the last review.

What is a GP chronic condition management plan?

A GP chronic condition management plan is a structured MBS service, billed under items 392, 393, 965, 967, 92029, 92030, 92060 and 92061, used by GPs and prescribed medical practitioners to plan the management of patients with one or more chronic conditions. The items are, in the words of explanatory note AN.0.47, "intended for patients that would benefit from a structured approach to managing their chronic condition(s)". They replaced GP Management Plans and Team Care Arrangements on 1 July 2025.

A patient is eligible if they have at least one medical condition that has been present, or is likely to be present, for at least 6 months, or is terminal. There is no list of eligible conditions. It is up to the practitioner's clinical judgment to determine whether an individual patient with a chronic condition would benefit from a plan, and no specific disease or pathological entity is required. AN.0.47 gives the example of a patient with chronic pain for more than 6 months where the underlying cause has not been diagnosed.

The service must also be clinically relevant, a requirement of the Health Insurance Act 1973. The Act defines a clinically relevant service as "a service rendered by a medical or dental practitioner or an optometrist that is generally accepted in the medical, dental or optometric profession (as the case may be) as being necessary for the appropriate treatment of the patient to whom it is rendered."

One exclusion matters at the front desk: GP chronic condition management plans are not available to people in residential aged care. Residents of a residential aged care facility may be eligible for a multidisciplinary care plan instead.

Which items do you bill?

The item you bill depends on who performs the service and the medium.

Items 965 and 967 carry a fee of $160.60, with a 75% benefit of $120.45 and a 100% benefit of $160.60, and an Extended Medicare Safety Net cap of $481.80. The video items 92029 and 92030 carry the same $160.60 fee with a 100% benefit of $160.60. Items 392 and 393 pay $128.55, with a 75% benefit of $96.45 and a 100% benefit of $128.55. You can check the current figures on item 965 on MBS Online and item 967 on MBS Online.

From 1 November 2026, four new phone items make GPCCMP services claimable by telephone for the first time: items 92033 (GP prepare) and 92034 (GP review) at $160.60 each, and items 92063 and 92064 (prescribed medical practitioner prepare and review) at $128.55 each. Before that date there is no MBS item for preparing or reviewing a GP chronic condition management plan by telephone, in any form. The phone fees are identical to the video and face-to-face fees, so there is no discount for doing the service by phone. The source is a legislative instrument, F2026L01101, registered on the Federal Register of Legislation on 24 August 2026, which inserts a new Subgroup 14 of Group A40 titled "GP chronic condition management plans services - Phone Services". The new items inherit the existing telehealth rules: the instrument threads them through the same restriction, co-claiming and same-day conditions that already govern the video items. We cover the full package in the 1 November 2026 MBS changes.

What has to be in the plan?

The Regulations do not leave the plan content to discretion. Preparing a GP chronic condition management plan is defined as the process whereby the GP or prescribed medical practitioner does five things, and the first is a written plan that describes six matters:

The condition and needs. The plan must describe "the patient's chronic condition and associated health care needs".

Goals. It must describe "health and lifestyle goals developed by the patient and medical practitioner using a shared decision making approach". The goals are not set for the patient.

Patient actions. It must describe "actions to be taken by the patient".

Treatment and services. It must describe "treatment and services the patient is likely to need".

Multidisciplinary referrals. If the patient would benefit from multidisciplinary care to manage the chronic condition, the plan must describe "the treatments or services to which the practitioner will refer the patient (including the purposes of those treatments or services)".

Review arrangements. It must describe "arrangements to review the plan (including the proposed timeframe for review)".

Then paragraphs (b) to (e) of the definition deal with the process around the document. If the patient is to be referred to a member or members of a multidisciplinary team, the practitioner must obtain the patient's consent to sharing relevant information (including relevant parts of the plan) with those members, and if the patient consents, provide relevant parts of the plan to them. The practitioner must record the patient's consent and agreement to the preparation of the plan, offer a copy of the plan to the patient and the patient's carer (if any, and if the practitioner considers it appropriate and the patient agrees), and add a copy of the plan to the patient's medical records.

Reviewing is defined separately. The practitioner discusses and documents the patient's progress in relation to the goals, and whether any updates should be made to the plan, taking into account whether the goals remain appropriate, the degree of progress towards meeting them, and information provided by members of the multidisciplinary team about their treatment of the patient and the extent to which their services are supporting the patient to meet the goals. The practitioner then updates the arrangements to review the plan (including the proposed timeframe for review), makes any other updates required as a result of those discussions, obtains and records the patient's consent to share relevant updated parts of the plan with the multidisciplinary team if the patient is to be referred, records the patient's consent and agreement to the updates, offers a copy of the updated plan to the patient and the patient's carer where appropriate, and adds a copy of the updated plan to the patient's medical records.

How often can a plan be prepared or reviewed?

A plan may be prepared no more than once every 12 months, and any new plan must be at least 3 months after the last review. A plan may be reviewed no more than once every 3 months. Both limits give way to exceptional circumstances, which the Regulations define as "there has been a significant change in the patient's clinical condition or care circumstances that necessitates the performance of the service for the patient".

Whether to review or prepare a new plan at the 12-month mark is a matter for clinical judgement. For most patients, unless there is a major change in clinical condition or other circumstances, periodic reviews are likely to be appropriate. A new plan can be prepared every 12 months, but this is not required.

What the regulator or assessor expects

The plan is between the GP or prescribed medical practitioner and the patient. A practice nurse, Aboriginal and Torres Strait Islander health practitioner or Aboriginal and Torres Strait Islander health worker may assist with preparing or reviewing the plan as appropriate, but the practitioner must see the patient as part of the service and is responsible for it. There is no minimum amount of time, but all MBS requirements must still be met: the practitioner must attend the patient, have a discussion with them about the plan, and be satisfied that the patient understands and agrees with the plan (including actions they are to take), even where a practice nurse or health practitioner has assisted.

Item 10997 and its telehealth equivalents cannot be used or co-claimed when a practice nurse or Aboriginal and Torres Strait Islander health practitioner assists with the preparation or review of a plan. The preparation and review items are complete medical services.

A member of the multidisciplinary team is defined in the Regulations as a person who "(a) provides treatment or a service to the patient; and (b) provides a different kind of treatment or service to the patient than each other member of the multidisciplinary team; and (c) is not an unpaid carer of the patient." This can include health professionals who provide MBS-supported services (medical specialists, allied health providers, Aboriginal and Torres Strait Islander primary health care professionals) as well as providers who do not, such as disability support workers. There is no requirement for a provider to agree to accept the referral before the plan or review is finalised; the plan should set out the multidisciplinary services the patient will be referred to.

Per calendar year, a patient with a plan may be eligible for up to 5 individual health services (10 for patients of Aboriginal or Torres Strait Islander descent), up to 5 services provided by a practice nurse or Aboriginal and Torres Strait Islander health practitioner on behalf of a medical practitioner, and, if the patient has type 2 diabetes, one assessment of their suitability for group allied health services and, if suitable, up to 8 group allied health sessions. A referral is required for MBS benefits to be payable for allied health and Aboriginal and Torres Strait Islander health and wellbeing services, and those referrals remain valid until all services under the referral have been provided, or they expire.

On the enforcement side, the Professional Services Review's dominant trigger through 2025 was non-individualised chronic disease management plans, alongside breaches of the 80/20 rule. We set out the pattern in detail in what the PSR is targeting in care plans.

Common mistakes

Reusing a legacy GPMP or Team Care Arrangement template under the new item numbers. Legacy care plan templates carried into the new item numbers compound documentation risk, and the plan has to describe the matters the Regulations set out, including health and lifestyle goals developed by the patient and medical practitioner using a shared decision making approach.

Co-claiming item 10997 when a practice nurse assisted. Item 10997 and its telehealth equivalents cannot be used or co-claimed when a nurse or health practitioner assists with a plan preparation or review.

Preparing a new plan when a review was the right service. A new plan requires at least 3 months to have passed since the last review, and a new plan every 12 months is permitted but not required. For most patients a periodic review is the appropriate service.

Claiming a review inside 3 months without documenting exceptional circumstances. The particulars need to be in the patient's record, and the invoice, Medicare voucher or digital claim needs to say that exceptional circumstances apply.

Assuming the plan expires at 12 months. Plans do not expire. The rule that bites is the 18-month one: the plan must have been prepared or reviewed within the last 18 months for the patient to keep accessing allied health and Aboriginal and Torres Strait Islander health and wellbeing services.

Assuming a multidisciplinary provider must accept the referral before the item can be billed. There is no such requirement. The plan or review can be finalised without that prior acceptance.

Frequently asked questions

What is a GP chronic condition management plan?

It is an MBS service, billed under items 392, 393, 965, 967, 92029, 92030, 92060 and 92061, used by GPs and prescribed medical practitioners to plan the management of patients with one or more chronic conditions who would benefit from a structured approach. The patient must have at least one condition present or likely to be present for at least 6 months, or a terminal condition. The plan's content is defined word for word in the Regulations.

What replaced the GP Management Plan and Team Care Arrangement?

The GP chronic condition management plan replaced both, on 1 July 2025. The GPMP and Team Care Arrangement items are gone, and the new preparation and review items, with their video and (from 1 November 2026) phone equivalents, carry the service. Explanatory note AN.0.47 on the Medicare Benefits Schedule sets out the full arrangement.

What are the GPCCMP item numbers?

GPs bill 965 to prepare and 967 to review face to face, 92029 and 92030 by video, and 92033 and 92034 by phone from 1 November 2026. Prescribed medical practitioners bill 392 and 393 face to face, 92060 and 92061 by video, and 92063 and 92064 by phone from the same date. The GP items pay $160.60 and the prescribed medical practitioner items pay $128.55.

How often can a GP chronic condition management plan be reviewed?

A plan may be reviewed no more than once every 3 months. A new plan may be prepared no more than once every 12 months, and at least 3 months must have passed since the last review. Exceptional circumstances, meaning a significant change in the patient's clinical condition or care circumstances that necessitates the service, override both limits if documented and flagged on the claim.

Can I bill a GPCCMP by phone?

Not before 1 November 2026. From that date, items 92033 and 92034 (GP) and 92063 and 92064 (prescribed medical practitioner) make preparation and review claimable by telephone for the first time, at fees identical to the video and face-to-face items. The instrument, F2026L01101, was registered on 24 August 2026 and is law, not a proposal.

Can a practice nurse prepare a GP chronic condition management plan?

No. A practice nurse, Aboriginal and Torres Strait Islander health practitioner or Aboriginal and Torres Strait Islander health worker may assist, but the plan is between the GP or prescribed medical practitioner and the patient. The practitioner must see the patient, discuss the plan with them, be satisfied the patient understands and agrees, and take responsibility for the service. Item 10997 cannot be co-claimed when a nurse assists.

Last reviewed 6 September 2026