In developing alternate assessments based on modified academic achievement standards (AA-MAS), several states have modified existing test items with the aim of enhancing accessibility and reducing difficulty for students with disabilities. Using Grade 8 multiple-choice test items in unmodified and modified forms, two studies examined student perceptions of item modifications and their effects on accessibility. Study 1 used a think-aloud cognitive lab to explore the effects of modifications on student perceptions and performance. Study 2 examined student survey data from a field test of the items with students (N = 709) with and without disabilities. Data indicated students generally perceived item modifications as helpful or positive. Educators and test developers are encouraged to consider students' perceptions of test items when designing tests.