That doughnut you ate for breakfast or cigarette you smoked after lunch may be costing you more than you thought.

As insurance costs rise, workers are finding their employers are trading in the carrot for a stick and hiking premiums upward of $1,000 annually if they don’t quit smoking or undergo urine or blood tests to assess their health. About 83 percent of U.S. companies offer incentives to employees who take part in wellness programs, and about 45 percent of those are tying the cost to the employee’s insurance premium or health savings plan, according to a new Aon Hewitt survey.

CVS Caremark drug store recently raised hackles when it told employees that its company health insurance would add a $50 monthly surcharge for workers who did not participate in its wellness program, which requires a confidential weigh-in and blood test. Many other companies are doing the same thing, but it’s almost always framed as an incentive rather than a penalty.

CVS is not alone with the surcharges.

At the not-for-profit MaineHealth group, smokers on the company insurance plan now face an annual $1,200 “tobacco fee” if a urine test shows recent tobacco use.

Until 2011, MaineHealth had used only incentives to encourage wellness among its employees.“The combination of carrot and stick seems to work better,” said Laurie Jones Mitchell, the director of Health & Productivity for MaineHealth. “Some people call it a ‘frozen carrot.’”

The tobacco fee is only one element of MaineHealth’s WebMD wellness program, which also offers cash incentives for employees who reach certain health standards. About 7 percent of MaineHealth’s 10,000 employees are currently paying the tobacco fee, Mitchell said. There has also been a big uptick in the numbers of people using the company’s free tobacco cessation programs and free tobacco medications, she said.

The size and type of the incentives (or consequences) of company wellness plans vary widely. Some only offer a $25 cash bonus for taking part, whereas others will increase your health care premiums more than $1,000 if you don't join a wellness program that requires an annual weigh-in and tests to determine blood sugar, blood pressure, cholesterol and nicotine levels. Those results are required to remain private with the employee's doctor or the wellness plan, but can impact how much your insurance costs.

Current law allows employers to tie the amount of the incentive up to 20 percent of the individual’s health care premium. In 2014, that percentage is expected to rise to 30 percent, and then up to 50 percent for smokers.

“Incentives are not necessarily a new thing,” said Stephanie Pronk, the Health Transformation leader for Health & Benefits at Aon Hewitt. But they are "absolutely" increasing, she said, based on Aon's survey of nearly 800 large and mid-size U.S. employers.

Aon has been studying these types of programs for about six years and found they were on the rise before the recent health care reform changes were approved. “We were seeing an overall uptick long before that came into play,” Pronk said.

And while the numbers are increasing, many employers are remaining on the sidelines, said Howard Bye-Torre, an attorney at Stoel Rives LLP in Seattle, who advises companies dealing with wellness plans.

“Some employers don’t really want to get into the issue of their employees’ health. They view it as very personal,” Bye-Torre said. Others, he said, are wary of the complicated federal regulations.

Among the complications is a possible conflict between the American Disabilities Act and the Health Insurance Portability and Accountability Act. While HIPAA specifically allows companies to offer financial incentives to employees who take part in wellness programs, the ADA states that any questions about an employee's health must be voluntary (and not coerced with an incentive of anything more valuable than a T-shirt or hat.)

The U.S. Equal Employment Opportunity Commission, which administers the ADA, has declined to clarify its stance on the apparent conflict, leaving some companies to wonder if there is a legal risk, Bye-Torre said. “Please give us guidance on these,” Bye-Torre said he and other attorneys have asked of the EEOC.

It’s well known that U.S. medical costs are more than double that of other developed countries, which is why, in a bid to lower insurance premiums, companies encourage their employees to be healthy.

Exercise, they urge workers, eat fresh fruits and vegetables, limit fast food and – above all – don’t smoke.

Sometimes this encouragement takes the form of a wellness plan – maybe offering $25 gift certificates to those who meet personal goals – but some companies take a more aggressive approach. This week, CVS Caremark made waves when it told employees to reveal their weight – or pay a monthly $50 penalty.

The drug retailing company is not alone, and as many TODAY readers pointed out – is mild compared to what they’ve gone through to lower health care premiums. Dozens said they had to give blood samples, although not all were upset by the requirement.

“My company already does something similar to this and I don't see the big deal,” said one reader. “Technically it isn't mandatory. You can either submit the basic info (BMI, glucose, cholesterol, blood pressure) and pay a discounted monthly rate, or not submit anything and pay the full monthly rate. It's just a discount for submitting the info – just like for my car insurance I get a discount for submitting my mileage and for being a ‘good driver.’"

One reader, self-described as 50 and “in relatively good health,” wrote: “We had to give information of weight, height etc., then the ‘plan administrators’ came back and told us what is wrong with us. … They even had a pedometer tethered to my hip for over 3 months to monitor my physical activity.”

But many readers lambasted CVS for invasion of privacy.

Wrote one: “This is a MASSIVE invasion of privacy that is headed towards your employer tell you what and how much food you can eat, the number of beers you can consume and what activity, i.e. motorcycling, rock climbing or anything that might even remotely be considered risky.”

One reader was sarcastic, noting that CVS sells cigarettes: “I wonder if CVS will eliminate their candy display and other unhealthy items they carry?”

Other readers argued that people need tough love: “It seems like the only way to do this anymore is to hit people where it matters ... in their wallet.”

Wal-Mart Stores Inc's U.S. employees will pay between 8 and 36 percent more in premiums for medical coverage in 2013, and now some of the 1.4 million workers at the nation's largest private employer say they will forgo coverage altogether.

In mailings sent to employees for its recently completed open-enrollment period, Wal-Mart noted that its rates would increase because healthcare costs continue to rise.

For its most popular plan, which covers individuals, the payment per bi-weekly paycheck is going up by $2, or 13 percent. Other plans will see larger increases as the world's largest retailer, known for low prices, tries to control its own costs.

Still, Wal-Mart said average costs its employees will bear should only rise about 4.4 percent in 2013, due to the elimination of some high premium plans, its move to offer free heart and spine surgery to most employees at six health care centers, and provision of other services, such as access to a healthcare adviser. That is less than the 9 percent average increase expected for all American workers next year, according to a study by human resources firm Aon Hewitt, though it isn't clear whether the figures are comparable.

Wal-Mart's example could be a blueprint for other employers trying to manage their costs while also preparing to meet the requirements of President Barack Obama's 2010 Affordable Care Act.

The law, the biggest reform to America's healthcare in decades, is intended to make healthcare less expensive but critics question whether it will succeed. It will also take years to fully implement. In the meantime, Wal-Mart and other large companies are trying to control their healthcare costs, which have been rising an average of more than 6 percent per year.

Wal-Mart pays for preventive care such as routine checkups. However, workers must pay deductibles of at least $1,750 before Wal-Mart covers 80 percent of the cost of other care such as doctor visits and diagnostic tests.

The retailer will also defray some costs with a separate contribution of $250 or $500 for individuals, and double that range for families.

Some workers say the price hikes for next year have pushed them to drop coverage.

"I really can't even afford it now so for it to go up even a dollar for me is a stretch," said Colby Harris, who said he makes $8.90 per hour and takes home less than $20,000 per year working in Wal-Mart's produce department in Lancaster, Texas.

Harris, a 22-year-old smoker, was set to see his cost per paycheck rise to $29.60 from $25.40. He says he has decided not to sign up for coverage.

More than half of Wal-Mart's U.S. employees sign up for its healthcare plans, which cover 1.1 million people, including dependents. Store workers across the country are offered the same plans as executives back at Wal-Mart's headquarters in Bentonville, Arkansas.

"Over the past few years we've all seen the cost of health care continue to rise nationwide, and 2013 is no different," Wal-Mart said in a statement. "As a result, we are adjusting rates for some of our health care plan choices. We are doing our best to keep health care costs as low as possible for our associates."

Barbara Andridge, who works at the Wal-Mart in Placerville, California, decided to drop out of a Wal-Mart plan provided for the retailer by a health management organization when she found out that the cost was set to nearly double to $60 a month.

"Sixty dollars isn't a lot to some people but when I have to think about buying winter clothes for my kids or sending my daughter to college I have to think of what is best for my children," she said. "Hopefully I'm making the right decision."

Andridge, who makes $12.05 an hour and said her husband was laid off this year, knows that she would have had to pay the same $60 monthly premium no matter how many hours she worked.

"Living paycheck to paycheck, I made the decision to swallow my pride and go and get county health," she said in reference to Medi-Cal, California's Medicaid health care program.

Wal-Mart has been touting its efforts to improve healthcare for its employees, including its October announcement that it would cover all costs, including travel, for costly, complicated heart and spine surgery at the six centers.

Nearly two-thirds of Wal-Mart employees sign up to cover only themselves. Rates covering individuals will rise $2 to $11 per paycheck, or 13 percent to 23 percent, according to documents viewed by Reuters. When plans covering families are included, rates rise anywhere from 8 to 36 percent.

Wal-Mart does offer some plans with premiums that are well below the national average.

Wal-Mart's lowest-cost and most popular associate-only medical plan will cost $17.40 per two-week pay period in 2013, up $2 from 2012. Costs for a single non-tobacco-using employee range from that to $59.30 per paycheck for 2013 (or $34.80 to $118.60 every four weeks).

According to the Kaiser Family Foundation's 2012 survey, the average monthly U.S. worker contribution this year was $79 per month for single coverage.

U.S. premiums are expected to rise 6.3 percent on average in 2013, human resources firm Aon Hewitt said in October, but premiums are just part of the costs story.

Newly hired part-time employees at Wal-Mart will have to work a minimum of 30 hours a week, up from 24 hours previously, before they qualify for coverage. The Affordable Care Act only requires larger employers to provide coverage for their staff who work at least 30 hours per week.

Other changes to Wal-Mart's 2013 plans, such as raising premiums, would have happened regardless of health reform, as it tries to control rising healthcare costs, the company said.

Harris and Andridge, who are dropping their coverage, are part of a group called OUR Walmart. Higher healthcare costs are one of the issues the group wants Wal-Mart to address, along with concerns such as wages and scheduling.

"Even if the plan only went up, let's say 50 cents, when you're barely making it every literal cent counts," said Harris.

OUR Walmart, which is not a labor union, is backed by the United Food and Commercial Workers International union, which represents workers at major grocery chains that compete with Wal-Mart. Members of OUR Walmart pay the organization dues of $5 per month.

Related stories:

• States get more time to plan health insurance exchanges
• A consumer's guide to health reform
• Workers opt out of company health plans

Most of us would rather have a root canal than read the paper work that comes with our health insurance plan. Now this process is a bit less painful thanks to new rules that require all private health insurance companies to provide a “Summary of Benefits and Coverage.” This eight-page form highlights what the policy covers and how much specific benefits cost.

Because every company must use the same format to provide this information, it should be much easier to comparison shop, whether you are buying coverage on your own or choosing a plan at work. This new form comes just in time for the annual open enrollment period when employees get to pick their coverage for next year.

“Instead of having a huge document with lots of fine print and gobbledygook, now in a relatively short document you’ll get clear language that will help you compare one plan from another,” said Ron Pollack, executive director of Families USA, a national organization for health care consumers.

Even if you aren’t choosing between plans, it’s important to know how you are protected. The new form, required by the Affordable Care Act, uses a question-and-answer format to accomplish that. On it are the following questions:

• What is the overall deductible?
• Are there other deductibles for specific services?
• Is there an out-of-pocket limit on my expenses?
• Is there an overall annual limit on what the plan pays?
• Does this plan use a network of providers?
• Do I need a referral to see a specialist?
• Are there services this plan does not cover?

If you don’t know the answers to these questions, you could make decisions that are not in your best interest and wind up paying more than expected for medical care out of your own pocket.

“We need all this because insurance companies have been hiding stuff from consumers for years,” said Nancy Metcalf, a senior editor at Consumer Reports. “Many people who had bad plans didn’t realize it because things were hidden. Now, every plan must have this form so you can lay them all out side-by-side and compare, something that’s been extraordinarily hard to do up to now.”

The new Summary of Benefits includes an extensive list of common medical events — such as a hospital stay, outpatient surgery, pregnancy, prescription drug purchases and treatment for mental health or substance abuse — and what you’ll pay if you use a preferred provider or an out-of-network provider.

The new form shows the types of expenses the plan would pay for if you had a baby or needed treatment for Type 2 diabetes. By using these two examples, you can get a general idea of how much financial protection is provided by different plans.

There’s also an explanation of common but often misunderstood insurance terms, such as deductible, copayments and preferred providers.

The insurance industry opposed the new rule when it was proposed, calling it a burdensome requirement that was too expensive. State insurance regulators welcome the change.

“Every day we hear from people who are concerned that they had a medical treatment that may not be covered by their plan,” said Stephanie Marquis with the Washington State Insurance Commissioner’s office.  “All of this can really impact the family budget.”

That’s why it’s so important to consider more than just the monthly premium when you choose a health insurance policy. You need to know what’s covered, what’s not covered and how much you’ll spend in deductibles and copayments.

“A surprise medical bill these days can be devastating to a family,” Marquis said. “That’s why this new summary form is such a big deal.”

More money and business news:

• Job seekers find warm welcome in Plains states
• Goodyear gets a bit too edgy with Lohan letter
• Listing of the Week: Which of these 2 islands will you buy?
• Video: You can still get free checking — here's how
• Sign up for our Business newsletter

Follow NBCNews.com business on Twitter and Facebook

The number of companies offering wellness perks, including everything from fitness club membership reimbursement to weight loss programs, has barely budged since the Great Recession started. But employers are increasing the pressure on employees to shape up anyway.

If you quit smoking or lose weight, more companies are willing to offer you discounts on those hefty insurance premiums today, according to a survey by the Society for Human Resource Management released Monday.

In 2009, only 4 percent of employers offered such breaks for weight loss, compared to 9 percent today. And 20 percent of companies offer the discount for smoking cessation, compared to 8 percent in 2009.

Society for Human Resource Management

But the number of companies providing smoking cessation classes has stayed at about 40 percent for the past four years. Also, fitness club subsidies has actually declined to 31 percent this year, down from 35 percent in 2009, but up from 30 percent last year. And weight loss programs have stayed around the 30 percent mark since 2009; rising slightly this year to 32 percent.

On the financial wellness side, more employers want workers to manage their own retirement. The study found that 92 percent of companies now offer defined contribution retirement plans such as 401(k), compared 21 percent of those offering traditional pensions. In 2008, the numbers were 83 percent and 33 percent respectively.

“By shifting primary responsibility in controlling certain healthcare and financial benefits, employers are recognizing a shift in workplace culture,” said Mark Schmit, vice president of research for SHRM. “The new plans allow employees have more control over how they save for retirement and manage their health, while reducing costs for employers. These plans are also more flexible, and thus more attractive, to employees who will likely not spend an entire career with one organization.”

In another area of employee health management, companies are further pushing medical screenings for employees. This year, 21 percent of companies offer insurance discounts for those workers who agree to take such health risk assessments, up from 10 percent just three years ago.

Such medical incentives, however, can sometimes run afoul of labor and medical privacy laws.

All medical data that comes out of health assessments is supposed to be kept strictly confidential. And under HIPAA, the total awards for participating in wellness programs cannot exceed 20 percent of an employee’s total coverage cost of the plan. But a provision in health care reform will up that number to 30 percent in 2014. The Americas With Disabilities Act also protects workers who may not be able to slim down, or can’t participate in company-sponsored exercise programs because of a disability.

 So what’s your take on employers working on slimming you down and having you take more financial responsibility for your future in the anticipation that you’ll be leaving soon anyway?

More money and business news:

• Women really can have it all if they toughen up
• $50K will get you into Pamela Anderson's bedroom
• Sorry Olive Garden, customers go even cheaper
• Video: Happy merry! Stores get ready for Christmas
• Sign up for our Business newsletter 

Follow Today Money on Twitter and Facebook.

Jose Luis Pelaez Inc / Getty Images stock

Ninety percent of uninsured workers said they didn't have insurance because it was too costly.

The weak economy continues to have a harsh effect on workers’ access to health insurance -- not necessarily because workers aren’t offered it but because they can’t afford it.

A new study from the Employment Benefit Research Institute finds that 55.8 percent of employees were getting health insurance directly from their employer as of April 2011, the most recent data available. That’s a nearly 5 percentage point drop from December 2007, when the economy first went into recession, and the researchers said early research shows that the number probably fell further.

The drop comes after more than a decade in which the rate of employees getting insurance in their own name held steady at around 60 percent.

It appears that it’s the cost, not the availability, of health insurance that is the primary thing keeping workers from getting insured. Ninety percent of uninsured workers said they didn’t have insurance because it was too costly.

The study was based on government data on workers age 18 to 64.

Paul Fronstin, director of EBRI’s health research and education program, said many employers have been gradually asking employees to foot more of the bill for their care through higher deductibles and co-payments.

“Employers have changed their focus to managing cost by changing the quality of the coverage that’s being provided,” Fronstin said. “You see more cost shifting and more employee responsibility when it comes to the cost of health care services.”

He said monthly premiums have not necessarily risen as much, but neither have wages. That may mean people feel like they are forking over a bigger slice of their paycheck for an insurance plan that requires higher and higher deductibles and other out-of-pocket expenses.

“It’s the value of the plan that’s changed more than the premium,” he said.

Some who drop their employer’s coverage may be switching to cheaper private plans or getting covered by a spouse, partner or parent. The percentage of workers who are covered as a dependent on someone else’s plan has held steady at around 17 percent.

Others may just be giving up health insurance altogether.

As the job market becomes stronger, some employers might start offering better health care benefits to compete for key employees.

But Fronstin noted that because employers generally make decisions about health care coverage six months to a year in advance, any improvements will likely lag quite a bit.

Related:

Health care costs rose faster than inflation despite weak economy

1 in 4 kids live in a family struggling with health care bills

Employee Benefit Research Institute

There are benefits to being in a union, literally.

Unionized workers are more likely to have health insurance coverage through their employer than their non-union peers. What’s more, they were less likely to lose their employer-based health insurance coverage during the recession than workers who aren’t in a union, according to a new study.

The Employee Benefit Research Institute crunched numbers from the U.S. Census data. They found that in 2009, 80.4 percent of unionized workers had health insurance through their job. That was a slight drop from 2007, when 82 percent of union workers had coverage through their employer.

By contrast, 52.2 percent of non-union workers had health insurance coverage through their job in 2009. That’s a steeper drop from 2007, when 55.9 percent of those workers were getting health insurance through an employer.

The numbers are even starker if you include people who were covered as a dependent on other health care plans. Then, 91 percent of union workers had health care coverage through an employer, while 70.6 percent of non-union workers had an employer-based health plan.

The No. 1 reason workers said they were uninsured was because they couldn’t afford the health care plan and had therefore declined it, according to the report. The second most common reason was that their employer didn’t offer a plan.

It’s not necessarily surprising that unionized workers would be more likely to have health insurance, since that’s the kind of benefit unions are likely to push for.  But unionized workers make up just a small part of the overall work force.

There were 14.7 million unionized workers in the United States in 2010, according to the Bureau of Labor Statistics.  Union members made up 11.9 percent of the workforce in 2010, compared to 13.4 percent of the workforce a decade ago.

Most recent graduates are stuck taking lower-paying jobs that are less likely to offer health insurance, according to a Rutgers University poll.

Just over half of the 571 graduates of public and private four-year schools surveyed by the school have full-time jobs, while just under half said their first jobs didn’t really require bachelor’s degrees. Nearly half said their parents are helping them financially.

The college graduates in the poll left school between 2006 and 2010. The survey found that those who graduated between 2006 and 2008 fared better than those who graduated in 2009 or 2010. The earlier grads were paid about $3,000 a year more in their first jobs, and 88 percent of them received health insurance, compared with 77 percent of the more recent grads.

The findings of the poll were reported by the Associated Press.