Medicare Benefits Schedule - Note AN.0.47

Publication date: 1 July 2025

SUMMARY

This note sets out the requirements for developing and reviewing GP chronic condition management plans. GP chronic condition management plans are used by GPs (see GN.4.13) and prescribed medical practitioners (see AN.7.1) to plan the management of patients with one or more chronic conditions.

GP chronic condition management plan items replaced GP Management Plans and Team Care Arrangements on 1 July 2025. For information on the transition arrangements for patients with an existing GP Management Plan and/or Team Care Arrangement see AN.15.5.

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 (see AN.15.8).

USE OF THE ITEMS

GP chronic condition management plans are intended for patients that would benefit from a structured approach to managing their chronic condition(s). The MBS items allow GPs and prescribed medical practitioners to work with their patients to set the goals for the patient’s treatment/management of their condition, roles and responsibilities, and a structured plan for their care.

Items 392, 965, 92029 and 92060 are for the preparation of a GP chronic condition management plan. The Health Insurance (General Medical Services Table) 2021 (the Regulations) defines preparing a GP chronic condition management plan as the process whereby the GP or prescribed medical practitioner:

"a. prepares a written plan for the patient that describes

i. the patient’s chronic condition and associated health care needs; and

ii. health and lifestyle goals developed by the patient and medical practitioner using a shared decision making approach; and

iii. actions to be taken by the patient; and

iv. treatment and services the patient is likely to need; and

v. if the patient would benefit from multidisciplinary care to manage the chronic condition, the services that the medical practitioner will refer the patient to (including the purposes of those services); and

vi. arrangements to review the plan (including the proposed timeframe for review); and

b. if the patient is to be referred to member of a multidisciplinary team for [management] of the patient’s chronic condition:

i. obtains the patient’s consent to sharing relevant information (including relevant parts of the plan) with the members of the multidisciplinary team; and

ii. if the patient so consents—provides relevant parts of the plan to the members of the multidisciplinary team; and

c. records the patient’s consent and agreement to the preparation of the plan; and

d. offers 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

e. adds a copy of the plan to the patient’s medical records.”

Items 393, 967, 92030 and 92061 are for reviewing a patient’s GP chronic condition management plan. The Regulations define reviewing a plan as the process by which a GP or prescribed medical practitioner:

"a. discusses and documents:

i. the patient’s progress in relation to the goals mentioned in paragraph (a) of the definition of preparing a GP chronic condition management plan; and

ii. whether any updates should be made to the plan taking into account:

iii. whether the goals remain appropriate and the degree of progress towards the goals; and

iv. information provided by members of the multidisciplinary team (if any) referred to in paragraph (b) of the definition of preparing a GP chronic condition management plan in relation to the members’ treatment of the patient and the extent to which the services provided by the members are supporting the patient to meet the patient’s goals; and

b. updates the arrangements to review the plan (including the proposed timeframe for review); and

c. makes any other updates to the plan required as a result of the discussions referred to in paragraph (a); and

d. if the patient is to be referred to a member or members of a multidisciplinary team for management of the patient’s chronic condition

i. obtains the patient’s consent to sharing relevant information (including relevant parts of the plan) with the members of the multidisciplinary team; and

ii. if the patient so consents—provides relevant updated parts of the plan to the members of the multidisciplinary team; and

e. records the patient’s consent and agreement to the updates; and

f. offers a copy of the updated plan to the patient and the patient’s carer (if any, and if the practitioner considers it appropriate and the patient agrees); and

g. adds a copy of the updated plan to the patient’s medical records."

Who are considered members of a multidisciplinary care team?

The Regulations define a member of the multidisciplinary team as a person who:

"1. provides treatment or a service to the patient; and

2. provides a different kind of treatment or service to the patient than each other member of the multidisciplinary team; and

3. is not an unpaid carer of the patient.”

This can include both health care professionals who provide MBS-supported services, such as medical specialists or allied health providers, as well as providers that do not provide services through the MBS, such as disability support workers.

When should a GP chronic condition management plan be considered?

Patients are eligible for a GP chronic condition management plan if they have at least one medical condition that has been (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 GP or prescribed medical practitioner’s clinical judgment to determine whether an individual patient with a chronic condition would benefit from a GP chronic condition management plan.

In considering the need for a structured plan, GPs and prescribed medical practitioners need to ensure the service is clinically relevant, which is 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.”

Patients with a GP chronic condition management plan may be eligible for a range of MBS-supported allied health services (see AN.15.4) and services provided by a practice nurse or Aboriginal and Torres Strait Islander health practitioner on behalf of a medical practitioner (see MN.12.4).

Does my patient need to be diagnosed with a specific disease or pathological entity to access GP chronic condition management plans?

No. Patients are eligible for a GP chronic condition management plan if they have at least one medical condition that has been (or is likely to be) present for at least 6 months, or is terminal.

For example, if your patient has had chronic pain for more than 6 months, and the specific underlying cause of the pain has not been diagnosed, it may be appropriate to put in place a GP chronic condition management plan to set out management goals and agreed patient actions. It may also be appropriate to consider referring them to allied health services such as exercise physiology services or psychological services to support the management of their condition.

What are the collaboration requirements? Do the members of the multidisciplinary care team need to agree before I can bill the item?

No. The plan should set out the multidisciplinary services that the patient will be referred to. There is no requirement for a provider to agree to accept the referral prior to the plan/review being finalised. For detailed information on referrals to allied health services see AN.15.6.

How frequently can GP chronic condition management plans be provided?

The Regulations provide for a plan to be:

• prepared no more than once every 12 months, and that any new plan must be at least 3 months after the last review
  
  
• reviewed no more than once every 3 months

unless exceptional circumstances apply (see below).

My patient has a GP chronic condition management plan for their asthma, which was reviewed 1 month ago. They have just been diagnosed with type 1 diabetes. Can I review their plan (or develop a new plan) and refer them to a diabetes educator and other appropriate services as a priority?

Yes, the Regulations provide for GP chronic condition management plan services to be provided to a patient sooner if exceptional circumstances apply. The Regulations define exceptional circumstances 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”. The particulars of the exceptional circumstances should be documented in the patient’s record to substantiate the claim.

Services Australia needs to be advised that exceptional circumstances apply to pay a benefit sooner than is generally allowable. To facilitate this the patient's invoice, Medicare voucher or the digital claim should indicate that exceptional circumstances apply, no further explanation is required to support payment.

My patient has had their plan for 12 months. Should I review the plan or prepare a new one?

This is a matter for clinical judgement. However, for most patients, unless there is a major change in their clinical condition (or other circumstances) that warrants a completely new plan it is likely that periodic reviews are appropriate. The review items allow the plan to be adjusted as required. While a new plan can be prepared every 12 months, this is not required.

Can anyone assist with preparing or reviewing the plan?

Yes, the Regulations allow for a practice nurse, Aboriginal and Torres Strait Islander health practitioner or Aboriginal health worker to assist with the preparation or review of the plan as appropriate. However, the GP chronic condition management plan is a plan between the GP/prescribed medical practitioner and their patient. It is a requirement that the GP/prescribed medical practitioner sees the patient as part of the service, and they are responsible for the service.

The items for preparing and reviewing a GPCCMP are complete medical services. Item 10997 (and its telehealth equivalents) cannot be used when a practice nurse or Aboriginal and Torres Strait Islander health practitioner assists with the preparation or review of a GPCCMP.

A practice nurse assisted with reviewing my patient’s plan. Can I claim item 10997 (or its telehealth equivalents)?

No, item 10997 cannot be co-claimed when a practice nurse assists with preparing or reviewing a GP chronic condition management plan. The items for preparing and reviewing a GP chronic condition management plan are complete medical services.

See MN.12.4 for further information on item 10997, including circumstances where co-claiming of 10997 and preparation or a review of a GP chronic condition management plan may be appropriate.

Is there a minimum amount of time I need to spend with the patient?

No. However, all MBS requirements must be met including that the GP or prescribed medical 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 if a practice nurse, Aboriginal and Torres Strait Islander health practitioner or Aboriginal health worker has assisted in preparing or reviewing the plan.

There will be several factors that determine how long this will take, including the complexity of their condition(s) whether this is the patient’s first plan, whether their condition is stable or has changed significantly, and whether their treatment goals remain the same.

Do GP chronic condition management plans expire?

No, GP chronic condition management plans do not expire. However, to promote continuous care for patients with a chronic condition, patients must have had their plan prepared or reviews within the last 18 months to continue to access allied health and other services.

How many allied health services can patients access?

Patients with a GP chronic condition management plan may be eligible for the following MBS‑supported services per calendar year:

• up to 5 individual allied health services (10 for First Nations patients) (see AN.15.4)
  
  
• up to 5 services provided by a practice nurse or Aboriginal and Torres Strait Islander health practitioner on behalf of a medical practitioner (see MN.12.4)
  
  
• if the patient has type 2 diabetes, one assessment of their suitability for group allied health services and, if they are suitable, up to 8 group allied health sessions (see MN.9.1 and MN.9.2).

Do patients need a referral for allied health services?

Yes, a referral is required for MBS benefits to be payable. For detailed information on referrals to allied health services see AN.15.6.

It is November and I would like to put a GP chronic condition management plan in place for my patient. Will it need to be reviewed before they can access their allocation of services next year?

No, patient’s eligibility is reset on 1 January every year automatically. You are not required to review their plan to enable services or otherwise reset the count provided patients continue to meet the eligibility requirements for the service.

To be eligible for services the patient must have had their plan prepared or reviewed within the previous 18 months.

It is December. If I issue new referrals for allied health services to my patient now, will they have to be reissued next year before they can access services?

No. Allied health referrals remain valid until all services under the referral have been provided, or they expire (see AN.15.6).

The MBS only provides for 5 individual allied health services per year. My patient would benefit from more. How do I determine what services I should refer them to?

This is a matter that should be discussed as part of the development plan. While the number of MBS-supported allied health services is fixed at 5 per calendar year. some patients can access additional services using private health insurance extras cover, non-MBS services (e.g. through state or PHN programs), or self-funding.

For patients who don’t have access to non-MBS services, services should be prioritised, in discussion with the patient. Factors to consider when prioritising services include clinical need and the patient’s management goals for their condition.

My patient is willing and able to fund additional allied health services this year. Which services will the MBS support?

MBS benefits are patient benefits. Up to 5 individual MBS-supported allied health services are available each calendar year for patients with a chronic condition management plan. Ultimately it is up to the patient to decide how they use their MBS benefits. When considering which services they should use their MBS benefits for patients may wish to consider factors such as the total cost of the service (and therefore any likely out of pocket costs) and the availability of any other support (e.g. private health insurance cover).

My patient only used 3 allied health services this year. Do the unused services carry over into next year?

No, unused services do not rollover. Patients are eligible for up to 5 services per calendar year regardless of any prior claiming patterns.

My patient needs physiotherapy services but I am not sure how many services they need. Can I still refer them?

Yes. You are not required to specify the number of services in the referral.

My patient has a GP chronic condition management plan. I know that allied health services are to be provided consistent with the plan. Is it ever appropriate to refer my patient to an allied health service under their plan for an acute condition?

It may be appropriate if the acute condition is likely to exacerbate the patient’s chronic condition or the chronic condition led to the acute condition. For example:

• Mrs Jones has COPD and diabetes. She has a GP chronic condition management plan which includes goals relating to maximising exercise tolerance and keeping her feet healthy. She has existing allied health referrals to an exercise physiologist and podiatrist. However, she contracts acute pneumonia and in conjunction with her GP it is determined she would benefit from chest physiotherapy to assist with her recovery. A referral is provided to a physiotherapist consistent with her goal to maximise exercise tolerance.
  
  
• Jim, 42, has type 2 diabetes. It’s generally been well controlled, and he has a GPCCMP. His goals include maintaining a tight HbA1c as he is relatively young, and to assist with this he has been referred to an exercise physiologist and a diabetes educator. However, whilst exercising he has an accident, and a nail ends up embedded in the plantar surface of his foot. The GP removes it under local anaesthetic but is concerned that the wound may be slow to heal due to previous wound healing issues. Therefore, the following day his GPCCMP is reviewed and goals updated to incorporate maintenance of foot health and prevention of ulceration. He is also referred to a podiatrist for assistance with wound care, pressure off-loading at the wound site and appropriate footwear for optimal healing.

Can I include social prescribing in my patient’s GP chronic condition management plan?

The GP chronic condition management plan is intended to set out the agreed actions and services that would be beneficial to the patient in managing their chronic condition. There is nothing that precludes the inclusion of activities or services that are not covered by MBS funding arrangements, such as social prescribing. However, it is important that patients are aware when services that are not supported by the MBS are included in their plan.

Do I need to upload the plan to My Health Record?

GPs and prescribed medical practitioners are strongly encouraged to upload GP chronic condition management plans to the patient’s My Health Record. However, as upload is not a requirement of the item it is not essential that the plan be uploaded prior to submitting an MBS claim.

ELIGIBLE PATIENTS

To be eligible for a GP chronic condition management plan patients must:

• have at least one medical condition that has been (or is likely to be) present for at least 6 months, or is terminal, and
• either:
  
  
  • Be living in the community (i.e. they are not a care recipient in a residential aged care facility), or
    
    
  • For face-to-face items only, be an in-patient of a private hospital. Patients that are public in-patients of a hospital are not eligible for these services.

Patients registered under MyMedicare must access GP chronic condition management services through the practice where they are registered. Patients that are not registered through MyMedicare can access the services through their usual medical practitioner. The Regulations define ‘usual medical practitioner” as:

“a general practitioner or prescribed medical practitioner:

1. who has provided the majority of services to the person in the past 12 months; or

2. who is likely to provide the majority of services to the person in the following 12 months; or

3. located at a medical practice that:

a. has provided the majority of services to the person in the past 12 months; or

b. is likely to provide the majority of services to the person in the next 12 months.”

Telehealth items – 92029, 92030, 92060, 92061

These items are not subject to the established clinical relationship rule (see AN.1.1) that applies to most general practice telehealth items. Instead, these items are subject to the same MyMedicare and usual medical practitioner requirements of the GP chronic condition management plan face to face items.

Consistent with the general rules applying to telehealth services, items 92029, 92030, 92060, 92061 cannot be used when the patient is an admitted patient of a hospital.

ELIGIBLE PRACTITIONERS

GP chronic condition management plan items are available for different medical practitioner types:

• General practitioner items can be claimed by GPs only (see GN.4.13)
  
  
• Prescribed medical practitioner items can be claimed by prescribed medical practitioners only (see AN.7.1)

Name of Item	GP item number	Prescribed medical practitioner item number
Prepare a GP chronic condition management plan – face to face	965	392
Prepare a GP chronic condition management plan - telehealth	92029	92060
Review a GP chronic condition management plan – face to face	967	393
Review a GP chronic condition management plan – telehealth	92030	92061

Noting that, under certain circumstances a GP chronic condition management plan services can be provided to a patient in a hospital, the Regulations state that the care items can only be used by medical practitioners that:

• are not employed by the proprietor of a hospital that is not a private hospital, or
  
  
• is employed by the proprietor of a hospital that is not a private hospital and provides the service otherwise that in the course of employment by that proprietor.

CO-CLAIMING RESTRICTIONS

Planning and review items for GP chronic condition management plans cannot be co-claimed by the same practitioner on the same day for the same patient as general attendance items (note the date of service should be recorded as the date the attendance occurred):

• items 3, 4, 23, 24, 36, 37, 44, 47, 52, 53, 54, 57, 58, 59, 60, 65, 123, 124, 151 and 165
  
  
• items 179, 181, 185, 187, 189, 191, 203, 206, 301, 303, 733, 737, 741, 745, 761, 763, 766, 769, 2197 and 2198
  
  
• items 585, 588, 591, 594, 599 and 600
  
  
• items 5000, 5003, 5020, 5023, 5040, 5043, 5060, 5063, 5071 and 5076
  
  
• items 5200, 5203, 5207, 5208, 5209, 5220, 5223, 5227, 5228 and 5261
  
  
• items 91790, 91792, 91794, 91800, 91801, 91802, 91803, 91804, 91805, 91806, 91807, 91808, 91890, 91891, 91892, 91893, 91900, 91903, 91906, 91910, 91913, 91916, 91920, 91923, 91926, 92210 and 92211.

RECORD KEEPING AND REPORTING REQUIREMENTS

Providers are responsible for ensuring services claimed from Medicare using their provider number meet all legislative requirements and they may be required to submit evidence for compliance checks related to Medicare claims. Practitioners should ensure they keep adequate and contemporaneous records. For information on what constitutes adequate and contemporaneous records see GN.15.39.

Clause 4.3 of the Health Insurance Act 1973 specifies that, where an item specifies the creation of a document (however described) and a document it created, the document must be retained for the period of 2 years. 

RELEVANT LEGISLATION

Details about the legislative requirements of the MBS item(s) can be found on the Federal Register of Legislation at www.legislation.gov.au. GP chronic condition management plan items are set out in two regulatory instruments:

• Health Insurance (General Medical Services Table) Regulations 2021 – items 392, 393, 965, 967
  
  
• Health Insurance (Section 3C General Medical Services – Telehealth and Telephone Attendances) Determination 2021 – items 92029, 92030, 92060, 92061

Related Items: 392 393 965 967 92029 92030 92060 92061

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Video attendance by a general practitioner to prepare a GP chronic condition management plan for a patient

Fee: $156.55 Benefit: 100% = $156.55

(See para AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6 of explanatory notes to this Category)

Video attendance by a general practitioner to review a GP chronic condition management plan prepared by the general practitioner or an associated medical practitioner

Fee: $156.55 Benefit: 100% = $156.55

(See para AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6 of explanatory notes to this Category)

Video attendance by a prescribed medical practitioner to prepare a GP chronic condition management plan for a patient

Fee: $125.30 Benefit: 100% = $125.30

(See para AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6 of explanatory notes to this Category)

Video attendance by a prescribed medical practitioner to review a GP chronic condition management plan prepared by the prescribed medical practitioner or an associated medical practitioner

Fee: $125.30 Benefit: 100% = $125.30

(See para AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6 of explanatory notes to this Category)

Professional attendance by a general practitioner to prepare a GP chronic condition management plan for a patient

Fee: $156.55 Benefit: 75% = $117.45 100% = $156.55

(See para AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6 of explanatory notes to this Category)

Professional attendance by a general practitioner to review a GP chronic condition management plan prepared by the general practitioner or an associated medical practitioner

Fee: $156.55 Benefit: 75% = $117.45 100% = $156.55

(See para AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6 of explanatory notes to this Category)

Professional attendance by a prescribed medical practitioner to prepare a GP chronic condition management plan for a patient

Fee: $125.30 Benefit: 75% = $94.00 100% = $125.30

(See para AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6 of explanatory notes to this Category)

Professional attendance by a prescribed medical practitioner to review a GP chronic condition management plan prepared by the prescribed medical practitioner or an associated medical practitioner

Fee: $125.30 Benefit: 75% = $94.00 100% = $125.30

(See para AN.0.47, AN.15.3, AN.15.4, AN.15.5, AN.15.6 of explanatory notes to this Category)