Chronic conditions management

Chronic conditions are not passed from person to person, they are of long duration and generally slow progression.  The four main types are cardiovascular diseases (eg. heart attack and stroke), cancers, chronic respiratory diseases (eg. chronic obstructed pulmonary disease and asthma), and diabetes.  A chronic condition usually lasts for more than three months and do not have a single, predominant condition, but rather they experience multimorbidity which is the presence of two or more chronic conditions in a person at the same time.

Chronic conditions kill nearly 40 million people every year, with cancer, diabetes, respiratory disorders, and cardiovascular disease accounting for about 80% of deaths due to chronic conditions.  Mental health is also considered a chronic condition

If your patient has a chronic medical condition, they may be eligible for services under the following:

• General Practitioner Management Plan (GPMP)
• Team Care Arrangements (TCAs)
• Mental Health Case Conferences (MHCC)
• General Practitioner Management Review
• Mental Health Case Conference Review
• Medication Review

From 1 July 2025, MBS Online's new framework for chronic disease management - Upcoming Changes to Chronic Disease Management Framework - will come into affect. 

The new framework aims to simplify, streamline, and modernise the arrangements for health care professionals and patients.

These changes primarily affect medical practitioners, however, allied health professionals providing MBS services should be aware of the changes to plan and referral requirements.

Transition arrangements will be in place for two years to ensure current patients do not lose access to services.

From 1 July 2025:

• Items for GP management plans (229, 721, 92024, 92055), team care arrangements (230, 723, 92025, 92056) and reviews (233, 732, 92028, 92059) will cease and be replaced with a new streamlined GP chronic condition management plan.
• The updated framework will be known as chronic condition management.
• To support continuity of care, patients registered through MyMedicare will be required to access the GP chronic condition management plan and review items through the practice where they are registered. Other patients will be able to access the items through their usual GP.
• Where multidisciplinary care is required, patients will be able to access the same range of services currently available through GP management plans and team care arrangements.
• GPs and prescribed medical practitioners will refer patients with a GP chronic condition management plan to allied health services directly. The requirement to consult with at least two collaborating providers, as described under the current team care arrangements will be removed.
• Practice nurses, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers will be able to assist the GP or prescribed medical practitioner to prepare or review a GP chronic condition management plan.

To encourage reviews and ongoing care, the MBS fees for planning and review items will be equalised. The fee for the preparation or review of a plan will be $156.55 for GPs and $125.30 for prescribed medical practitioners. Patients will also need to have their GP chronic condition management plan prepared or reviewed in the previous 18 months to continue to access allied health services.

Consistent with current arrangements, unless exceptional circumstances apply, a GP chronic condition management plan can be prepared once every 12 months (if necessary) and reviews can be conducted once every 3 months. It is not required that a new plan be prepared each year, existing plans can continue to be reviewed.

Patients that had a GP management plan and/or team care arrangement in place prior to 1 July 2025 will be able to continue to access services consistent with those plans for two years. From 1 July 2027, a GP chronic condition management plan will be required for ongoing access to allied health services.

These changes do not affect multidisciplinary care plan items (231, 232, 729, 731, 92026, 92027, 92057, 92058).

For more information, MBS Online has released a selection of Factsheets here: MBS Online - Upcoming changes to the MBS Chronic Disease Management Framework.

For support on MyMedicare and upcoming CCM Changes, please contact primarycareengagement@nqphn.com.au