affirmative vote of two-thirds of the Members, duly chosen and sworn. . 4. Medicare point of order Section 301 of the Congressional Budget Act of 1974 ( 2 U.S.C. 632 ), as amended by section 3, is further amended by adding at the end the following: (k) Medicare point of order (1) In general It shall not be in order in the Senate to consider any bill or resolution (or amendment, motion, or conference report on that bill or resolution) for which the total budgetary effects of the measure, as determined by the Congressional Budget Office, use a decrease in outlays, or an increase in revenue, under the health insurance programs under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) to offset a cost of a provision of the measure that is not for the purpose of carrying out those programs. (2) Waiver Paragraph (1) may be waived or suspended in the Senate only by the affirmative vote of two-thirds of the Members, duly chosen and sworn. An affirmative vote of two-thirds of the Members of the Senate, duly chosen and sworn, shall be required to sustain an appeal of the ruling of the Chair on a point of order raised under paragraph (1). .