Since the implementation of the No Child Left Behind Act of 2001 states have experienced continual change in how they define and implement alternate assessments. A subset of 16 states was randomly selected to determine how each state is implementing alternate assessments and achievement standards for students with the most significant cognitive disabilities. Telephone interviews were conducted from January to August 2005, and a 32-item questionnaire was used to collect information on alternate assessment procedures. This article focuses on the ways states are interpreting how students with the most significant cognitive disabilities are held to the same content standards as their peers without disabilities, whether states exert quality control over the administration of the alternate assessments, and the costs of implementing alternate assessments. (Contains 7 figures and 1 table.)