This chapter underscores the importance of effective governance and oversight of Medicaid health plans as part of the foundation of meeting state contractual requirements and nurturing trustworthy relationships with key stakeholders. It discusses how effective governance may be achieved through a board of directors or a solid executive management team (depending on one’s organizational structure) that consistently delivers on its critical responsibilities, such as: promoting the health plan’s mission and values; hiring the best leaders; fostering relationships with external parties, especially the state Medicaid agency; monitoring performance of the health plan vis-a-vis the contractual requirements, and more. An important governance role is hiring the best leaders. Today’s leaders are sought for skills in the art and science of trust, influence, and exude authenticity, humility, integrity and transparency. This extends to the people who are on the board of directors, ensuring that it is comprised of individuals who are representative of local ethnicity and demographics and are influential leaders in the community, and may include executives from corporate offices. Effective governance and leadership of the Medicaid health plan is expected by state agencies, but it doesn’t happen by chance. The elements of how to comprise the best leaders, follow good governance principles and effectively execute key responsibilities are described in more detail.