ECONOMIC SERVICES ADMINISTRATION (ESA)
COMMUNITY SERVICES DIVISION (CSD)
Medical Expense Examples
Below are types of medical expenses that may be used to meet your
spenddown.
Please note: We can only use bills after Medicare Part A/B/D, the Medicare
Savings Program (MSP), or other insurers have paid their portion. If you’re on
the Qualified Medicare Beneficiary (QMB) program, we can’t use bills covered
by Medicare Part A/B.
Examples of common medical expenses:
1. If prescribed by a licensed provider (with proof) – over-the-counter
medications and supplies. These may include:
• Vitamins, pain relievers and herbal supplements.
2. Hospital, clinics, or other services:
• Doctor, dental, vision care.
• Approved in-home care services.
• Mental health services or counseling, or community case management.
3. Transportation costs related to doctor visits, picking up prescriptions or
medical supplies:
• Trips made in your personal vehicle.
• Parking or toll fees, fares for Dial a Lift, bus, ferry, taxi, or ride sharing
(Uber, Lyft, etc.).
• Lodging costs when away from home for medical treatment.
4. Service animal expenses such as food and veterinary care.
5. Medical equipment such as mobility aids, rehabilitative aids, prosthetic /
orthotic devices and Electronic Emergency Response Systems (EERS).
6. Medically needed improvements to the home to accommodate a person with
blindness or disability.
7. Out of state billing for medical services recognized under Washington state
law.
Please see next page for further instructions.
MEDICAL EXPENSE EXAMPLES Page 1 of 3
DSHS 17-301 (11/2020)
Proof of your medical expenses need to include:
1. Hospital, doctor, or other provider bills. Statements must include all of the
following:
• Patient’s name;
• All pages sent with the statement;
• Provider’s contact information;
• Statement date within the current base period;
• Date(s) of service and total charges and/or cost of care;
• Payments made by third parties (Medicare, MSP, or other insurance); and
• Final balance owed by patient.
2. Prescription(s). Proof must include all of the following:
• Patient’s name, pharmacy name;
• Medication name and prescription number;
• Payments by third parties (Medicare Part D or other); and
• Final balance owed by patient.
Examples of how you can show proof:
• A register receipt and pharmacy receipt; or
• Prescription summary with pharmacist’s signature; or
• Medicare Part D Summary
3. Transportation costs with date(s) of travel:
• Mileage log – see the Mileage Log Sample on the next page.
• Receipts for fees or fares, such as parking, bus fares, etc.
MEDICAL EXPENSE EXAMPLES Page 2 of 3
DSHS 17-301 (11/2020)
Mileage Log Sample
ROUND PARKING
DATE PROVIDER’S NAME PROVIDER’S ADDRESS TRIP IN FEE (ADD
MILES RECEIPT)
Example 1: Harborview 325 9th Ave., Seattle 15 $20
01/03/2020
Example 1: Walmart Pharmacy 1000 Greenlake, 20
01/05/2020 Seattle
Mileage Log
ROUND PARKING
DATE PROVIDER’S NAME PROVIDER’S ADDRESS TRIP IN FEE (ADD
MILES RECEIPT)
MEDICAL EXPENSE EXAMPLES Page 3 of 3
DSHS 17-301 (11/2020)
