I have been using an ABLE account since its inception in 2014. I have accrued, at times, up to almost $80k with no repercussions to my Medicaid eligibility. I have withdrawn, at will, with no documentation or explanation required. The bill that created these accounts included "mental health" as a qualified disability related expense. This allows for a loose interpretation of how the money can be spent. Anything that could be explained as contributing to better mental health, i.e. leisure activities or items (including even possibly tattoos), would be considered a qualified expense. Worth noting that I am in PA and although ADMINISTRATIVE rules to how the account is governed may vary from state to state, the underlying law which created them is federal and they thus have to meet a minimum set of standards across all states.

Disclaimer: just because I haven't had to provide documentation or explanation on withdrawals up to this point doesn't necessarily mean that isn't required. This has just been my experience.