AGREEMENT & DISCLOSURE STATEMENTMedicare Advantage Medical Savings Account Agreement • August 31st, 2022
This Medicare Advantage Medical Savings Account Agreement and Disclosure Statement (this “Agreement”) is entered into by and between the account owner (referred to in this Agreement as “you” and “your”) and The Bank of New York Mellon (referred to in this Agreement as “we”, “us”, and “our”). It specifies the terms of the Medicare Advantage Medical Savings Account (“MSA”) you are opening with us (your “Account”). Your Account is as an individual custodial account established in accordance with the statutory requirements of Section 138 of the Internal Revenue Code (the “Code”) governing Medicare Advantage MSAs, and we will serve as the custodian for your Account pursuant to this Agreement. You cannot make deposits into your MSA. Medicare, by way of your Medicare Advantage Health Plan, will deposit funds as part of your Medicare Advantage benefits by check or electronic transfer into your MSA. Your Medicare Advantage Health Plan, on behalf of the Centers for Medicare and Medicaid Services
