Quick answer
These are MBS items letting GPs prepare structured care plans for patients with ongoing needs. From 1 July 2025 the old Chronic Disease Management items were replaced by the GP Chronic Condition Management framework: item 965 to prepare a plan (fee $156.55) and item 967 to review it. A plan unlocks up to five Medicare-subsidised allied health services a year. Separately, a GP Mental Health Treatment Plan (item 2700, or 2715 with recognised training) gives patients up to 10 rebated psychology sessions a year.
Where care plans fit
The proactive, planned work you already do as a GP, chronic disease reviews, care coordination, mental health planning, has a specific home in the Australian system. Rather than sitting inside a practice-level incentive scheme like QOF, it is billed directly through MBS items you prepare and review for an individual patient, and those items often open referrals to subsidised allied health.
Two areas dominate: chronic disease and mental health, both reformed recently, so check current detail rather than an old summary. The Department of Health and MBS Online carry the items and rules in force.
Chronic condition management plans
On 1 July 2025 the long-standing GP Management Plans and Team Care Arrangements, two separate documents, were folded into a single GP Chronic Condition Management Plan, with new MBS items for preparing and reviewing it.
The plan is a structured record of a patient's chronic condition, the goals of care, the treatments and actions agreed, and the other providers involved. Preparing one as a GP is item 965, with a scheduled fee of $156.55; reviewing it later is a separate service, item 967, which attracts the same $156.55 benefit for a GP. (The equivalent items for a prescribed medical practitioner are 392 and 393, at $125.30, and video versions exist for each.) A review is available every three months where clinically relevant, and transition arrangements let patients who held a plan under the old system keep accessing services for a defined period.
To claim item 965 you assess the patient, agree health and lifestyle goals with them, set out the treatments and services they will use, record who else is involved, and specify a date to review the plan. Fees and timing rules can move, so confirm current figures on the Services Australia billing rules and MBS Online.
Who is eligible and how it works
Eligibility is broad and clinically judged rather than tied to a fixed list. A patient generally qualifies if they have at least one chronic medical condition, one that has been, or is likely to be, present for at least six months, or that is terminal. There is deliberately no set list of qualifying diagnoses, so the decision rests on whether structured, planned care will help.
The rhythm of prepare, coordinate and review will feel natural to any GP who has run chronic disease clinics; the Australian layer is that each stage maps to a defined MBS item.
A patient with a chronic condition likely to last six months or more.
Set goals, agree treatments and actions, note the providers involved.
Where relevant, refer to subsidised allied health services.
Revisit the plan at appropriate intervals and adjust as needed.
Allied health referrals
The main reason the plans matter to patients is that they open the door to subsidised allied health. With a plan in place, you can refer the patient under the allied health items 10950 to 10970 to providers such as physiotherapists, podiatrists, dietitians and exercise physiologists. The patient can claim a maximum of five of these services in a calendar year across all providers combined, and each must run at least 20 minutes and be consistent with the plan.
A referral written on or after 1 July 2025 stays valid for the timeframe you specify, or for 18 months from the first service if you set none. The five-service cap is shared, so if a patient uses three physiotherapy sessions they have two left for any other allied health that year. The count and rules can move, and additional services apply for Aboriginal and Torres Strait Islander patients, so confirm on MBS Online.
Mental health treatment plans
The other major strand is mental health. A GP Mental Health Treatment Plan under the Better Access initiative is a structured plan for a patient with a mental health condition. Preparing one is item 2700 if you have not completed mental-health-skills training (20 to 40 minutes) or item 2715 if you hold training recognised by the General Practice Mental Health Standards Collaboration (GPMHSC); items 2701 and 2717 are the longer, 40-minutes-plus versions. The GPMHSC training carries a higher rebate but is not required to prepare a plan, and it counts toward your ongoing CPD.
The plan gives the patient access to subsidised therapy: up to 10 individual and 10 group Medicare-rebated sessions with eligible psychologists and other mental health professionals per calendar year. From 1 November 2025 the dedicated plan-review items were removed, so you review a mental health plan using standard time-tiered attendance items, not within four weeks of preparing the plan or more than once every three months. Session limits sit on the Services Australia pages.
Margaret, 62, has type 2 diabetes and osteoarthritis, both well past the six-month mark, and has been low in mood since her husband died.
- Chronic condition plan. In a longer consultation you prepare a GP Chronic Condition Management Plan (item 965, fee $156.55): goals for her HbA1c and weight, her medications, and a review date. You refer her under the allied health items (10950 to 10970) to a dietitian and a podiatrist, using two of her five subsidised services for the calendar year and leaving three for later.
- Review. A few months on you review the plan (item 967) to check her progress against those goals and update the medications, and she still has three allied health services left under the same referral.
- Mental health plan. At a separate visit you prepare a GP Mental Health Treatment Plan (item 2700 without recognised training, or 2715 with it), which lets her claim up to 10 individual Medicare-rebated psychology sessions this year. You review her mental health at a later standard consultation rather than a dedicated review item.
Two plans, several defined items, and a patient who can now afford a dietitian, a podiatrist and a psychologist she would otherwise have paid for in full.
Billing the plan items
You can bulk-bill or privately bill the plan items subject to the item rules, exactly as with a standard consultation. Their higher fees reflect the extra work a structured plan involves, so at $156.55 a preparation is worth appreciably more than a short attendance, and they flow into your earnings under the percentage-of-billings model alongside your choice of billing model.
Adjusting from the UK
If you have run chronic disease clinics or done mental health planning in UK general practice, the clinical work here will feel familiar. The reviews, the goal-setting, the coordination, the safety-netting all transfer directly; what differs is the funding architecture around it.
In the UK, structured care is largely rewarded at the practice level, through frameworks like QOF and enhanced services, so the individual GP does not usually bill for each plan. In Australia, it is delivered through individual MBS items that you personally prepare, review and bill, and those items directly attach subsidised services for the patient. The shift is from a practice-incentive mindset to an item-based one, the same adjustment you make across the whole of Australian general practice. The time you spend on thorough care is recognised rather than absorbed, and it matters most in rural and regional areas where access to allied health can be tighter.
Using them well in practice
The practical side is mostly handled by your practice's systems: templates, recall systems and software prompts for plan preparation and review are standard, and your orientation will cover how your practice runs them. A few habits make care plans work well. Write plans that reflect real, individualised care rather than boilerplate, because that is both good medicine and what the items require. Book reviews at sensible intervals. Match allied health referrals to the patient's goals, and settle the GPMHSC training early if you want the higher mental health rebate.
Sources
These are the primary sources behind this guide. Read them directly and confirm anything time-sensitive on the day.
| Topic | Official source |
|---|---|
| Changes to chronic disease management (2025 reform) | Dept of Health, Disability and Ageing |
| GP chronic condition management plan (billing rules) | Services Australia |
| Medicare Benefits Schedule (plan items) | MBS Online |
| Better Access initiative (mental health) | Services Australia |
| Mental health treatment plan template | Dept of Health, Disability and Ageing |
| MBS billing rules for mental health services | Services Australia |
| RACGP guidance on CDM changes | RACGP |
| Mental health CPD (GPMHSC) | GPMHSC (RACGP) |
| What Medicare covers | Dept of Health, Disability and Ageing |
| Medicare for health professionals | Services Australia |
Frequently asked questions
What replaced the old CDM items in July 2025?
How do patients access subsidised psychology?
What changed for mental health items in November 2025?
Do chronic condition plans include allied health?
Which patients are eligible for a chronic condition management plan?
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