• A  single GP chronic condition management plan (GPCCMP)  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

Upcoming Changes to Chronic Disease Management Framework

• Upcoming Changes to Chronic Disease Management Framework
• MBS Items – Transition Arrangements for Existing Patients
• Framework – Referral Arrangements for Allied Health Services
• Framework – MBS Items for GP Chronic Condition Management Plans
• Framework – What Do the Changes Mean for Allied Health Providers?
• Framework – What Do the Changes Mean for Practice Nurses, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers?

• MyMedicare practices should setup and maintain their Organisation Register including:
  • Ensure your Organisation Site Record details are correct (see Organisation Register – Health Professional Education Resources).
  • 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).
  • Link your patients to their preferred GP in the Organisation Site Record.
  • 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).
  • 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).

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

• If you are the patient’s usual practice for ongoing care (e.g., GP Chronic Conditions Management), encourage them to register for MyMedicare with your practice.
• If a patient prefers another general practice for ongoing care, do not register them at your practice. Encourage registration and attendance at their preferred practice, especially for ongoing care 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.

• The General Practice in Aged Care Incentive
• GP Chronic Conditions Management Plans
• Telephone Level C and D MBS items
• Triple Bulk Billing Incentives for video and telephone consultations that are longer than 20 minutes[1] (Levels C, D and E) for eligible MyMedicare patients registered with the practice.

• 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.
• 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.

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

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  

• Template Updates: GP Management Plan (GPMP/GPCCMP) & Review – Adult (New) 

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