What Is a Chronic Disease Management Plan? The Allied Health Practitioner's Guide
By The Kitt Team
A patient hands you a letter from their GP. Somewhere near the top it says “GP Chronic Condition Management Plan”, or maybe the patient just describes it as a “CDM plan” or “care plan”. You know roughly what it means: Medicare-funded sessions, some paperwork back to the GP. But as of 1 July 2025, the administrative framework changed. If you’ve been running on muscle memory from the old GPMP and Team Care Arrangements, take a few minutes to get the current picture right.
A chronic disease management plan gives patients with a qualifying chronic or terminal condition access to subsidised allied health services under Medicare. The instrument is now officially called the GP Chronic Condition Management Plan (GPCCMP). As the treating allied health clinician, you can deliver up to five Medicare-rebated services per calendar year for eligible patients, ten for Aboriginal and Torres Strait Islander patients. After those services, a reporting obligation runs back to the referring GP. That obligation didn’t change on 1 July 2025. The rest of this article breaks down what did, what didn’t, and where allied health clinicians most often get tripped up.
A GPCCMP Gives Patients Subsidised Allied Health Access Through Medicare
The chronic disease management plan, now formally the GPCCMP, sits within Medicare’s chronic disease framework. It pairs structured GP care with allied health involvement for patients whose conditions are chronic or terminal: present for at least six months, or likely to persist that long.
Eligibility isn’t determined by a fixed diagnostic list. The GP makes the clinical call, based on the nature and expected duration of the patient’s condition. Type 2 diabetes, chronic low back pain, heart failure, COPD: these turn up regularly in allied health caseloads under this pathway. So do less common presentations. The six-month threshold is the test, not a pre-approved diagnosis code. If the GP has deemed a patient eligible and prepared the plan, that determination is theirs to make.
For allied health clinicians, the pathway matters because it extends access to patients who might otherwise skip necessary care, or pay full out-of-pocket rates for it. Medicare reimburses around $61.80 per eligible service at the time of writing, that figure is indexed, so treat it as a current approximation rather than a fixed promise. For a broader overview of how care plans interact with Medicare’s allied health provisions, see Medicare care plans for allied health.
What Changed on 1 July 2025
Before 1 July 2025, the framework ran on two instruments: the GP Management Plan (GPMP) and Team Care Arrangements (TCA). You needed both. The GPMP documented the patient’s care goals. The TCA brought in at least two other treating practitioners and formally established collaborative care. Allied health Medicare access hung off the TCA.
On 1 July 2025, both were replaced by a single instrument: the GP Chronic Condition Management Plan, or GPCCMP. The GP now prepares one document that covers what the old GPMP and TCA handled separately. One plan, one process, one referral letter that follows a specialist-referral format.
For allied health clinicians, the practical effect is modest. You still receive a referral from the GP. You still deliver services under Medicare. You still report back. The main change is what disappears: you no longer need to formally accept the referral, and you no longer contribute to the preparation of the plan itself. That administrative layer is gone.
Many patients and GPs will still say “CDM plan” or “care plan” in conversation. The underlying instrument is the GPCCMP, but that distinction rarely needs correction at reception. If a patient mentions an “EPC plan”, see enhanced primary care plans: what the term means now.
How a Patient Reaches You: The Referral Letter, the Cap, and the Rollover Rule
Under the current framework, the GP sends a letter of referral, structured like a specialist referral, not a form-based document. This letter authorises the patient to access Medicare-rebated allied health services under their GPCCMP.
Services per calendar year. Up to five Medicare-rebated allied health services per patient, per year. For Aboriginal and Torres Strait Islander patients, that cap is ten. The five (or ten) services are shared across every allied health provider on the plan, not per discipline; the Medicare 5-visit rule explains the shared cap and intake checks.
No rollover. Unused services lapse on 31 December. A patient who uses two sessions in November has three remaining before year’s end, not three to access at any point going forward. If this affects your treatment planning, factor it in early.
No formal acceptance required. The previous requirement to formally accept the referral no longer applies. Receiving the letter and booking the patient in is sufficient.
The 18-month rule. The GPCCMP generally needs to have been prepared or reviewed within the previous 18 months for a patient to access related allied health services. If a patient presents with an older plan, a quick call to the GP before committing sessions is worth the two minutes.
For detail on what a referral letter should contain and how to handle gaps in referral documentation, see allied health referral letters.
What You Must Document and Report: This Is Where It Counts
The reporting obligation hasn’t changed. It existed under the old GPMP/TCA framework, and it carries over directly under the GPCCMP. Miss it, and you risk breaking continuity of care for the patient and leaving the GP without the clinical information they need to manage the plan. Clear SOAP notes from each session make those GP reports much faster to write.
The rule is clear: you must provide a written report to the referring GP after the first service, after the last service, and whenever there is a clinical need for the GP to be informed.
All three triggers apply. The first and last are automatic. The clinical-need trigger requires judgement.
What counts as clinical need? A significant change in presentation. A finding outside what you anticipated. A decision to modify the treatment approach substantially. Anything the GP would reasonably want to know before the patient’s next consultation. It’s not a bureaucratic threshold. It’s a clinical judgement call, and it should err on the side of informing.
What a good report covers:
The written report doesn’t need to be long. It needs to be useful. At minimum, cover three things:
- Assessment: What you found at the relevant session, referenced against the patient’s presenting condition and the goals documented in the GPCCMP.
- Progress: How the patient is tracking against those goals. Be specific. “Progressing well” carries no clinical weight. “Achieved a 15-degree increase in shoulder flexion, still 20 degrees short of the documented goal” does.
- Recommendations: What you plan to do next, what you’d ask the GP to consider, or both. If you’re changing your approach, say so here and say why.
Keep the language clinical and direct. GPs read these reports between appointments. They don’t need narrative. They need the facts, laid out so they can act on them quickly.
The reporting obligation also protects you. A documented written report creates a clear record that you fulfilled your professional obligations under the referral. It shows the GP what occurred at each stage of care and provides a defensible account of your clinical reasoning. When a patient changes providers, or when the GP updates the plan at the 18-month mark, that record is what makes handover clean rather than chaotic.
An AI clinical assistant such as Kitt can draft the written GP report and clinical notes a chronic disease management referral requires, from the session, for the clinician to review and send.
Common Questions
Is a CDM plan the same as a GPCCMP now?
Yes. From 1 July 2025, the GP Chronic Condition Management Plan replaced the GP Management Plan and Team Care Arrangements. Patients and GPs will often still say “CDM plan” or “care plan” in conversation. The current Medicare instrument is the GPCCMP.
How many allied health sessions does a patient get under a chronic disease management plan?
Up to five Medicare-rebated services per calendar year for most patients. Aboriginal and Torres Strait Islander patients can access up to ten per year.
Do unused sessions roll over to the next year?
No. Unused services lapse on 31 December. There is no rollover provision.
Do I still have to formally accept the referral?
No. That requirement was removed on 1 July 2025. The GP’s letter of referral and booking the patient in is sufficient.
When do I have to report back to the GP?
After the first service, after the last service, and on clinical need. All three triggers apply. Written reports are required, not optional.
Key Takeaways
- A chronic disease management plan (now formally the GPCCMP) gives patients with a chronic or terminal condition access to subsidised allied health services under Medicare.
- Eligibility rests on the clinical nature and likely duration of the condition, at least six months, not a fixed list of approved diagnoses. The GP determines eligibility.
- From 1 July 2025, the GP Management Plan and Team Care Arrangements were replaced by a single instrument: the GPCCMP. Allied health session caps and reporting obligations are unchanged.
- Patients receive up to five Medicare-rebated allied health services per calendar year; ten for Aboriginal and Torres Strait Islander patients. Unused services do not roll over past 31 December.
- Formal acceptance of the referral is no longer required. The GP’s letter of referral is the trigger.
- Written reports to the referring GP are mandatory after the first service, after the last service, and on clinical need. A useful report covers assessment, progress against plan goals, and recommendations.
Know the Framework, Do the Paperwork
The GPCCMP framework isn’t complex. The referral process is cleaner now, and one administrative requirement has dropped away. What hasn’t changed is the part where allied health clinicians most often fall short: the written report back to the GP.
A missed report is not just an administrative gap. It leaves the patient’s GP without the information they need, and it leaves you without a clear record of what occurred under the referral. The patient is the one who pays for that gap when their care plan comes up for review.
Get the referral letter. Know the session cap. Write the reports. That’s the framework, in practice.
Medicare fees and item descriptors are subject to indexing and legislative change. Verify current rebate amounts and GPCCMP requirements on the MBS Online website or with your professional association before billing.