Requirements for a chronic disease health care plan

Requirements to understand before creating a Chronic Disease Management (CDM) plan.

CDM plans help eligible health professionals coordinate health care for patients with chronic or terminal medical conditions.

You can read about billing Chronic Disease GP Management plans and Team Care Arrangements items.

Planning and management items are intended to be provided by the patient’s usual medical practitioner.

The patient’s ‘usual medical practitioner’ means a GP, a non-vocationally recognised medical practitioner (non-VR MP), or practitioner at the same practice who:

  • has provided most of the care to the patient over the previous 12 months, and/or
  • will be providing most of the care to the patient over the next 12 months.

You or your delegate can check your eligibility for Medicare benefits through the MBS items online checker in HPOS. You can also call Medicare.

CDM services help you coordinate health care for patients with chronic or terminal medical conditions. These medical conditions are present or are likely to be present for 6 months or longer or are terminal.

You or your delegate can check patient eligibility and claiming conditions in the MBS items online checker in HPOS. You can also call Medicare.

You can view a patient’s care plan history in HPOS.

Other health professionals can help eligible practitioners deliver some services, including:

  • CDM plan development
  • monitoring and support services.

Health professionals can help to prepare, contribute and review CDM plans, including:

  • performing patient assessment
  • identifying patient needs
  • arranging for services.

Eligible practitioners must meet all Medicare item requirements, including:

  • reviewing and confirming assessments
  • attending the patient.

Read about the relevant MBS item descriptions, fact sheets and explanatory notes on the MBS Online website.

Practice nurses and Aboriginal and Torres Strait Islander health practitioners can monitor and support CDM plans on behalf of medical practitioners.

They can provide support of up to 5 services per calendar year for a patient who has a current CDM plan.

The service must be:

  • provided on behalf of and under the supervision of the eligible practitioner
  • consistent with the patient’s CDM plan.

You can lookup patient eligibility for MBS item numbers through the MBS items online checker in HPOS. Read about MBS item descriptions, fact sheets and explanatory notes at MBS Online website.

You can view a patient’s care plan history in HPOS.

You may decide that your patient would benefit from a referral to allied health. They can receive 5 individual services each calendar year.

Patients are eligible for MBS CDM allied health services if you have completed both:

  • General Practitioner Management Plan (GPMP)
  • Team Care Arrangements (TCAs).

Read about allied health referrals for chronic disease health care plans.

You can review a plan once every 3 months. You can provide these services more frequently in exceptional circumstances. For example, when there is a significant change in a patient’s condition.

We suggest that practices call and encourage patients to attend an appointment to review their care plan.

You can claim CDM review items for the plan and Team Care Arrangements (TCAs).

Read about the relevant MBS item descriptions, fact sheets and explanatory notes on the MBS Online website.

Page last updated: 15 June 2024.
QC 74075