State and federal mandates for education reform call for increased accountability and the inclusion of students with disabilities in all accountability efforts. In the rush to implement high-stakes education reforms, particularly those involving tests or assessments, the particular needs of students with severe cognitive disabilities are only now being addressed by policymakers and educators. For students with significant cognitive disabilities, implementation of alternate approaches to education accountability is increasing. At the same time, the challenges associated with successfully implementing alternate assessment programs are becoming more obvious. This paper describes some of the ways in which alternate assessment as part of standards-based education reform may impact students with significant cognitive disabilities. It provides an overview of state efforts to implement alternate assessments for students with significant cognitive disabilities, followed by an example of how one state has begun to implement alternate assessment through the Massachusetts Alternate Assessment (MCAS-Alt/ Massachusetts Comprehensive Assessment System Alternate). It reviews issues educators in all states will face in the participation of students with significant disabilities in alternate assessment programs, the content and form of alternate assessments, the validity and reliability of the assessments, and the role of teachers in the implementation of alternate assessment programs.